Tuesday 4 October 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

Ontario Recreation Society

Malcolm Bromley, president

Lynn Briggs, community facilitator

Catholic Women's League of Canada

Patricia Beattie, member, Ontario provincial executive

Moira Ste Marie, member, Ontario provincial council

Dorothy McGuigan, president elect, Toronto council

City of Toronto long-term care negotiating committee

Dr Perry Kendall, chair

Beatrice Levis, representative

Elizabeth Amer, representative

Evelyn Fisher

Citizens for Independence in Living and Breathing

Margaret Wagner, representative

Steve McPherson, representative

Tom Wagner, representative

Association of Ontario Health Centres

Sonny Arrojado, executive director

Margaret Myers

Victorian Order of Nurses (Ontario): Durham region branch; Metropolitan Toronto branch; Peel branch; Simcoe county branch; York region branch

Marg Purkis, member, board of directors, VON, Metro Toronto.

Charles Style, member, board of directors, VON, Simcoe county

Phil Curtis, president, board of directors, VON, Durham region

Carole Burtch-Rudderham, executive director, VON, Peel region

Ontario Chiropractic Association

Bob Haig, director, government affairs

David Chapman-Smith, general counsel

Association of Community Information Centres in Ontario

Carol Jones-Simmons, membership development coordinator

Monica Stewart, vice-president

Pamela Gray

Canadian Union of Public Employees, Ontario division

Sid Ryan, president

Donna Powell, member, health care workers' committee

Margaret Evans, researcher

Service Employees International Union

Judi Christou, assistant to the president, Local 204

Marcelle Goldenberg, director, research

Ontario Association of Non-Profit Homes and Services for Seniors

Dan Oettinger, president

Michael Klejman, executive director

Kevin Mercer, president-elect

Ad Hoc Consumer Coalition on Long-Term Care

Patti Bregman, representative

Ontario Association for Community Living

Cheryl Easton, president

Jim Mahaffy, first vice-president

Learning Disabilities Association of Ontario

Eva Nichols, consultant, advocacy legislation and government liaison

Ontario Association for Volunteer Administration; Ontario Association of Directors of Volunteer Services in Healthcare; Volunteer Ontario

Lorraine Street, executive director, Volunteer Ontario

Carol Dixon, president, Ontario Association of Directors of Volunteer Services in Healthcare

Lynn Ziraldo, president, Ontario Association for Volunteer Administration

Coalition de planification de l'organisme de services polyvalents francophone du grand Toronto

Omer Deslauriers, représentant / representative

Central East Regional Group of District Health Councils

John Rogers, chair


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

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

*Acting Chair / Président suppléant: McGuinty, Dalton (Ottawa South/-Sud L)

*Carter, Jenny (Peterborough ND)

Cunningham, Dianne (London North/-Nord PC)

Hope, Randy R. (Chatham-Kent ND)

*Martin, Tony (Sault Ste Marie ND)

*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

Also taking part / Autres participants et participantes:

Ministry of Health:

Wessenger, Paul, parliamentary assistant to the minister

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

Czukar, Gail, counsel, legal services branch

Clerk / Greffier: Arnott, Doug

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

The committee met at 0908 in room 151.


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

The Acting Chair (Mr Dalton McGuinty): Good morning, ladies and gentlemen. Welcome to the standing committee on social development's continuing hearings into the matter of Bill 173, An Act respecting Long-Term Care.


The Acting Chair: Our first presenters this morning will be presenting on behalf of the Ontario Recreation Society. Please step forward and have a seat. Good morning. Would you please introduce yourselves for the record and then begin.

Mr Malcolm Bromley: Good morning. I'm Malcolm Bromley, the president of the Ontario Recreation Society. Lynn Briggs is the community facilitator from the Ontario Recreation Society specific to Bill 173, and Wendy Murdock is our executive director. Thank you for giving us this opportunity to address the committee. We've distributed some materials before you which hopefully will help clarify some of the things we're about to state and a video for you to view later.

The Ontario Recreation Society, for those of you who are not aware, is one of the largest and most diverse professional organizations representing recreation in Ontario. Established in 1970, the society's ultimate objective is to enhance leisure and recreation services throughout the province. The society's 600-plus membership is involved in a vast array of services in most district health council geographic areas. Members come from the public service, community agencies, institutions, industry, volunteer organizations, education and the general public. Services are provided to a diverse consumer group, and there is little doubt as to the importance leisure and recreation services play in their lives and communities and in the economy and the environment.

In a review of research studies, Allen in 1991 found that there is conceptual and empirical support for recreation and leisure areas, services and opportunities as contributors to community life satisfaction. He cites one study by Allen and Beattie, 1984, that found a recreation dimension to be the best predictor of overall satisfaction with community life.

Recreation is seen as an effective way for people of different cultures to come together and to develop a sense of community, with an opportunity to interact with people from other ethnic backgrounds. This was determined in a study by the city of Toronto parks and recreation department, 1989.

Recreation constitutes a major opportunity for people with disabilities to socialize and enjoy social interaction. Leisure is a critical component to quality of life and contributes to health status. This was determined by Burt Perrin Associates, 1989.

Given this relationship, it's often assumed that recreation and leisure are aspects of everyday life that simply happen for people and that those individuals who value recreation will seek it out and be able to access it. For the majority in our society, this is a feasible proposition. However, there are increasing numbers of people in our communities for whom this assumption does not hold. Tangible support systems must be in place for these people. Many individuals who will be affected by the reform of our long-term care system will benefit from an integration of community and health support services and systems. We are concerned for those less able to take advantage of these services.

The recreation profession is already well connected to the community and often plays a coordinating function with many other community and health service providers. The role of the professional recreation provider must be maintained and enhanced within the reform process and framework, not left to chance for discretionary consideration.

The basic principles and goals of long-term care reform and Bill 173 complement and echo the foundation upon which recreation services are designed. We believe in both local and individual focus with maximum consumer input.

The Ontario Recreation Society generally supports and endorses the goals and principles of long-term care reform and Bill 173. However, more must be done to entrench recreation as a critical element. We are certain that the profession is responding to the critical issues that our citizens and communities face in the 1990s and believe that decision-makers must fully integrate and recognize the role of the qualified recreation professional. This includes Bill 173 specifically and those responsible for its development.

Ms Lynn Briggs: To reiterate, the Ontario Recreation Society is pleased that Bill 173 has identified social or recreational services as a community support service that multiservice agencies must provide or ensure the provision of. All consumers of long-term care services will have leisure needs, and at least on the surface Bill 173 appears to have acknowledged this fact.

From a consumer perspective, evidence suggests that recreation is considered a vital part of rehabilitation, prevention and ongoing wellness. Leisure and recreation are among the core support services which currently assist people to remain involved and connected as active members of their communities. However, Bill 173 has not identified social or recreational services. As a result, there is potential danger in district health councils interpreting and delivering the service in an ineffective and inconsistent manner via the multiservice agency.

In addition, consumers, recreation professionals and other service providers are more familiar with the service being identified as leisure and recreation services. Social contact and socialization are benefits of leisure and recreation participation as opposed to a direct service area. All leisure and recreation services have in fact a social component. Therefore, we recommend that references to "social or recreational services" be renamed to "leisure and recreation services" in Bill 173. It is further recommended that the service be specifically defined under part II, subsection 2(1), with input from the profession through the Ontario Recreation Society.

Investment in recreation as a preventive health service makes perfect sense. With reference to the purposes of Bill 173, we believe that continued investment in this service area will positively impact on the health and wellness of consumers of long-term care.

The government has made a commitment to incorporate wellness into its design work for all programs and services in the long-term care system. It is our belief, however, that the system design in general continues to adhere to the medical model of service delivery, where expensive and intensive treatment appears to be a priority over the more cost-effective benefits of wellness-oriented service provision. While it is prudent to build upon the good parts of our current system, it takes a true redirection to integrate health and social services in a way where health promotion and wellness become the primary focus of all service provision.

As recreation professionals, we are very familiar with the long-term social and physical benefits derived from adopting the principles of independent, healthy and active living. In other words, we believe that we "walk the wellness talk" on a daily basis by the very nature of the services we provide.

Active living generally, through the opportunity of leisure, is one of the very best methods of health insurance for individuals. There is an extensive body of research, some of which we have provided for you, indicating the ways in which recreation and leisure interact with a person's health and general sense of wellbeing.

To varying degrees, all services that are to be provided by a multiservice agency have health promotion and wellness components, but often it is not a primary focus of their service provision. Leisure and recreation services consider health promotion and wellness to be a primary benefit of participation and, as such, have a vital role to play in any plan of service for individuals utilizing the long-term care system. We are aware that a provincial policy framework on wellness related to long-term care client groups is currently under development, but we have to wonder why more reference is not made to health promotion and wellness in Bill 173 legislation.

Even though the benefits of leisure and recreation services appear to be crystal-clear, in our work at the district health council level we have been witness to the near or absolute exclusion of social or recreational services as a necessary partner in the circle of service to be included in the multiservice agency design.

The Ministry of Culture, Tourism and Recreation has produced a video -- you also have a copy of that in front of you -- titled Growing Stronger: The Benefits of Sport and Recreation. The video reiterates the benefits of investment in recreation by stating: "Public sector funding of recreation programs illustrates the old adage: Pay now or pay more later.... An investment made today achieves and maintains increased physical and mental health among the population, lessening future health care costs." This would suggest that it would be prudent to ensure that sufficient financial resources are maintained to provide for leisure and recreation services for consumers and care givers.

The Ontario Recreation Society is able to provide details of recreation service provision options which are fiscally responsive, which have proven effective in rehabilitation and health promotion and which have incorporated collaborative planning with consumers, their families and other service personnel. However, due to the vast array of service options in terms of leisure and recreation, the Ontario Recreation Society believes that the purchase-of-service limitations for multiservice agencies will severely restrict the consumer's right and accessibility to choice of service options. Therefore, we recommend that social or recreational services be exempt from any purchase-of-service limitations.

The leisure needs of consumers must not be overlooked. Leisure provides the opportunity to lead balanced lives, achieve our full potential and gain life satisfaction. The opportunity of leisure is essential.

Mr Bromley: In conclusion, the Ontario Recreation Society reaffirms our commitment to working as a collaborative partner in the reshaping of the long-term care system in this province. We believe our service is essential to the consumers of long-term care and we are working diligently in our communities to ensure the provision of the service within multiservice agency frameworks for them. The inclusion of leisure and recreation services cannot be left to chance, and we are confident that the recommendations contained in this brief will assist in positioning this service as an integral and essential part of the service framework in communities across the province.

In short, the benefits of leisure and recreation services cannot be ignored. Investment in recreation makes sense.

Ms Jenny Carter (Peterborough): Thank you and welcome to the committee. I don't think there's any dispute that wellness has to be the prime focus and that we want to keep people well rather than see them get sick when that could have been prevented. It seems to me that some of that is programmed into what we're doing. I'll just outline what I see as being there, and perhaps you could tell me what you feel needs to be added to the mix, as it were.

Certainly in Bill 101, which covered the institutional side of long-term care, I know that programming of various kinds is funded. I believe it's left to the individual place to decide what they will spend that money on, but I believe that component is in there.


For people who remain in the community, I think what we're looking at is -- I don't know whether you'd call it a day centre or what, but somewhere where a person can go and spend one or several days a week. It seems to me that there would be recreation within that, as part of what they would do during that day. Certainly I know that in my own riding of Peterborough we have Activity Haven Seniors' Centres and we have places where people can go and do carpet bowling or sing or whatever. Also, I've visited places which are centres for seniors where they have things like line dancing and t'ai chi and so on. So those things are there in the mix. I'm just wondering what you feel needs to be done, what you feel is inadequate about the situation.

Ms Briggs: We certainly agree that there are services available in the community at present. That's not really what our issue is. Our issue is that there is a population or clientele of long-term care consumers that we believe will not be assisted to access those services through the MSA design. We have found that already in our work, as I stated, at the community level, that there are not any mechanisms at present being put in place to ensure this group of folks receives leisure in their lives, which we believe to be very important.

Mr Bromley: If I could just add a comment to that, the way we like to see it is that there are some bridges that need to be built between some of the existing services and some of the clientele who are receiving services through other methods now, through institutions and other traditional models of health care provision. The linkages are not quite there in some communities. We have, on a positive note and a constructive note, tried to help district health councils link up with local recreation providers to make sure those linkages are there.

So the active and the well can quite readily access traditional recreational and leisure services, as you outlined. It's those people who, for whatever reason, whether it's disability or age, have a number of barriers in front of them. We think that it is right now a leap of faith that the clients who are using long-term care facilities would be able to benefit from those services as presently developed.

Ms Carter: But of course there is a category of people who are not at the point where they need to access health services, who are being kept well because of things that are there anyhow.

Mr Bromley: Because of us.

Ms Carter: I mentioned Activity Haven. That would cater to a lot of people who wouldn't be calling that phone number to ask what services they could access because they're beginning to feel sick or whatever. So I guess if we're really looking at wellness, we're looking at people in that stage and hoping to keep them there so that they really wouldn't come under the orbit of the MSAs, but nevertheless the services should be there.

Mr Bromley: It's a range of service that needs to be in place, from those who are very active to those who are very inactive. But we all need leisure, we all need healthy recreation, and I think we can look at personal examples of ourselves and family members who, without that active leisure component, can slowly deteriorate and then become -- it's not only a human tragedy for the individual and the family; it's a fiscal tragedy for the province.

Ms Carter: Absolutely.

Mr Bromley: I understand that that's what we're all concerned about.

Ms Carter: As I say, we're looking at a continuum of services that starts outside the MSA framework, and then ultimately people would be included within that. I guess the services of that kind that are there already would come under an MSA. I wonder if we could maybe have some clarification on that, as to what the scope is likely to be, whether the things that cater specifically to wellness are going to be included under that umbrella.

The Acting Chair: Parliamentary assistant?

Mr Paul Wessenger (Simcoe Centre): I probably will ask the policy person to elaborate more, but it would appear to me that if we look at the people who would be served in the long-term care system in the community, it will be those people who are recovering from an acute care situation, which is about 50% of the people involved, I believe, and the other people are those we would call the frail elderly. Certainly I think it's the latter category, perhaps, the frail elderly, where you'd be looking at the social and recreational services. I think it's very clear that there is a need for some type of services to those people to enrich their lives.

I would assume that probably the best way of providing that would be through elderly persons' centres, but I will ask Mr Quirt. Perhaps he could add his more extensive knowledge in this area.

Mr Geoff Quirt: Certainly the elderly persons' centres are involved in an important way in providing social, recreational and leisure activities for elderly people. Normally, our contribution is in addition to the contributions made at the municipal government level, and often it's the municipal recreation department that has the primary focus on providing those services.

We make a modest contribution to elderly persons' centres, up to $30,000 a year. Clearly, elderly persons' centres, as our policy documents have indicated, should be considered in the planning for the new long-term care system and MSAs, but there's no problem with them remaining separate and being funded separately. For the very reason that the presenters have mentioned, the fact that often people with disabilities or frail elderly people have difficulty accessing leisure or recreation services, we made social recreational services a mandatory service for multiservice agencies to deliver. So each multiservice agency will have to pay attention, by law, to the social and recreational needs of its client group.

Ms Briggs: We were just concerned that the interpretation of multiservice agencies may be somewhat different than contained in the bill, and that's been our actual experience. So we wanted to come here today and reiterate the importance of the service.

Ms Carter: Certainly we see wellness as being very much part of it, and of course for seniors who are more active we do have the Ontario Seniors' Games program, which I saw quite a bit of this year. You have competitions in each local area and then they went to Sudbury for the finals. That was really quite a large project. It was funded, I believe, by the province. So that's looking at the point people are at before they would come under an MSA-type arrangement. I hope and believe that that's included.

The Acting Chair: Thank you very much for your presentation.


The Acting Chair: Our next presenters are here on behalf of the Catholic Women's League. Good morning. Welcome to the committee.

Mrs Patricia Beattie: My name is Patricia Beattie, and I'm a member of the Ontario provincial executive of the Catholic Women's League of Canada as well as president of the Toronto archdiocesan council of the CWL. With me today is Moira Ste Marie, another member of the provincial council, and Dorothy McGuigan, president elect of the Toronto council.

The Catholic Women's League has been active in communities across Ontario for over 74 years. We currently have over 65,000 members across the province, almost 8,500 of whom are based in Toronto.

Our members are active volunteers in their communities. They donate their time and raise money to support local organizations. In the Toronto archdiocese alone, we estimate that over 100,000 hours per year are spent by our members working with organizations such as the Arthritis Society, the cancer clinic, Meals on Wheels and Providence Centre and providing services such as non-medical palliative care, home visits and transportation. In the entire province, it is estimated that over 400,000 hours of volunteer time are spent on various tasks.

Over the years, the CWL has been active on various pieces of legislation at all levels of government. We increase our efforts when we have major concerns regarding the policies being proposed. We have serious enough concerns with some of the proposals contained in Bill 173 that we felt it important to state them publicly to you here today.


From our perspective, the piece of legislation which you are studying will do serious harm to the volunteer element of many organizations within our communities. Volunteers will be demotivated in terms of giving their time, sharing their expertise and raising funds for many needy organizations.

Working with volunteers every day, we are well aware of what is required to both attract them and keep them involved. Commitment must be built, they must feel that their contribution is valued, and they must believe that if they are not doing the job, the job would not be done and someone would be suffering.

Under the current provisions of Bill 173 and the resulting absorption of many community agencies into a government-mandated MSA, we do not believe these elements will exist. By leaving only the names and logos of organizations and taking away their independence, you will remove the individuality of the affected groups, their innovation, their spirit and the rationale for many to participate in their activities.

We have spoken with many of our members about this issue, and we always receive the same general response: "If the government is providing the service, our help is not required. The need is not the same. We will devote our energies to activities which need our help more."

As Minister Grier stated when she appeared before this committee, "As a volunteer...I decide what kind of agency is most compatible with the kinds of objectives I want to achieve and satisfactions I want to achieve as a volunteer, and if that agency doesn't provide me with that sense of satisfaction, well then, there are lots of other roles in which I can fulfil my volunteer responsibilities."

We agree. CWL members and councils work with a wide variety of organizations, some of which will be affected by this legislation and others which will not. It is not difficult for our members to refocus their activities and concentrate on projects such as working with homes for unwed mothers rather than delivering food as part of a local Meals on Wheels program, or increasing the time spent in home visits rather than assisting the Arthritis Society. Our members will not be the ones who suffer; rather, it will be those organizations and the people they serve, all of whom depend on the time given by volunteers to properly deliver their services.

Has the government taken these possible losses into consideration? Have you done the financial estimates of what it would cost to replace the lost volunteers with paid workers just to be able to continue the same level of services?

We have done some estimates of our own. Based on volunteer hours, estimated at 400,000 a year in Ontario, and using a sum of $15 per hour, the total amount of volunteer time spent by CWL members last year would cost $6 million to replace. Now, given that we do not devote all of our time to organizations which would be affected by Bill 173, we reduced that amount, cut it in half in fact. Even at that, the total remains over $3 million. In our view, that is a significant amount of lost resources which will have to be made up somewhere or services individuals need, and received in the past, will disappear. These figures are just for our organization, not taking any other volunteers into consideration. The CWL believes these are facts which must be given serious consideration by this government before it proceeds any further with the legislation.

Additionally, a significant amount of money is raised by CWL members which would likely be lost by the passage of this legislation, as well as the loss of volunteer time and commitment. Again, taking 50% of the total, we estimate that over $800,000 of forgone fund-raising moneys will be the result of Bill 173. If this money is not replaced from somewhere, services will be ended or cut as a result. Where will these extra dollars come from?

I would like to urge the government to take the views it has heard through these hearings, not just from us but from many other organizations which have grave concerns about this bill, and reconsider its future. From our perspective, the loss of volunteers and the associated cost of replacing them are too great to be thrown away in the current manner. The necessary parts of the bill -- easier access to information and the bill of rights -- can be achieved without the destructive sections which currently exist.

On behalf of the 65,000 members of the Ontario Catholic Women's League, we thank you for the opportunity to appear before you today.

Mrs Yvonne O'Neill (Ottawa-Rideau): Thank you very much for coming. Your brief is very explicit and self-explanatory. I think, if I may, I would like to go just a little bit below the surface of your brief. I understand that this morning at 11 o'clock you're going to be part of the coalition -- at least your name is on as one of the members of the coalition -- that has approached the Premier about the seriousness of what this bill entails.

I'd like to ask you, and I'm sure it won't be easy for you to give me the exact reasons, why you joined the coalition; what you see beyond what you have in your brief, which are two very poignant and fundamental reasons why this bill is certainly putting many organizations in jeopardy and certainly the efforts of many individuals whom you represent in question. I'd like to know what it's doing to those organizations that you so well describe that your members are part of, whether they be Meals on Wheels or whether they be the cancer society.

Could you say a little bit about what the effects are? There have been real criticisms that we're only hearing from the providers, that we're not really hearing from grass roots, and I think you're the grass roots.

Mrs Beattie: One of our very grave concerns is the loss of freedom of choice, not only for the consumer but, from our particular perspective, from the point of view of the volunteer. We would lose freedom of choice of what organizations and institutions we would support with our volunteer time and with our volunteer dollars.

Mrs Moira Ste Marie: If I may add to that, I really feel we are the grass roots, because we are assisting people in their homes. We are doing it at all stages of life, from the very young right through to the very old. Our women are people who have jobs, they are people who are at home, and they see the needs in their communities. So they relay those needs to members of this group, and people react because we are there for a common goal.

Mrs Dorothy McGuigan: May I add to that? The religious and cultural choices will not necessarily be there, because we are a religious-affiliated organization. For some of our elderly, religion and culture are very vital to their health and welfare. Through the existing non-profit organizations, a lot of the services are offered in three dozen languages. That may not necessarily be something that the large, monopolistic MSAs are going to have the ability to attain or to even afford. So this is something that concerns us, because we are a caring organization and we are really interested in the religious and cultural aspects of this bill.

Mrs O'Neill: I think you have represented the grass roots. I think the grass roots understand what this bill is about, and the fears and doubts are very well placed, I think. I'm just going to ask God to bless your every effort. Thank you very much for coming.

The Acting Chair: Thank you very much for your presentation.



The Acting Chair: Our next presenters are appearing on behalf of the city of Toronto long-term care negotiating committee. Welcome to the committee.

Dr Perry Kendall: Thank you for this opportunity to respond to Bill 173. I am here today not as a medical officer of health for the city but as chair of the city's long-term care negotiating committee, which was set up almost three years ago as part of a larger city-wide process for examining and responding to the government's redirection of long-term care. My copresenters, Ms Bea Levis is chair of the Toronto Mayor's Committee on Aging, and Councillor Elizabeth Amer also represents that committee. They will both be speaking today.

We in the city undertook in 1991 a six-month process of consultation where we talked with a host of stakeholders: seniors' networks, disabled persons' organizations, ethnocultural groups, service providers, informal care givers, residents of facilities, city departments, representatives of native Canadian seniors and the Social Planning Council of Metropolitan Toronto. What that taught us was that there are no new issues in long-term care reform. The old issues -- one-stop access, a full range of services in the right place at the right time, maximum allocation of precious resources to service delivery -- have been discussed long enough and well enough to warrant the current legislation. So I'd like to begin by expressing our great relief that Ontario is at the point, I believe, of putting in place a reformed system of long-term care.

The city's position regarding Bill 173 is outlined fully in the report from Toronto city council which has been tabled with this deputation. While the city supports the intent and much of the substance of Bill 173, the report does express some important concerns.

I'd first, however, like to note with approval the flexible framework for service delivery provided by the bill, a framework in which small service agencies can maintain their identity within a multiservice context. Building an improved system with these agencies will ensure an ongoing role for the groups and individuals who know their communities best and understand the needs of the people who live here. It will also, I believe, address the criticism that I just heard this morning that volunteers will lose their altruism and desert the new system. The visible continuation of agency identity will help assure their loyalty and responsiveness to community needs. I don't believe that the well of altruism in the Ontario community will dry up as a result of the proposed changes in this bill.

However, considering the legislation's flexibility and the purpose put forward in clause 1(g), to encourage local community involvement, subsection 11(3) of the act is perplexing. This is the section that states that before designating a municipality or a board of health as an MSA for a geographic area, the minister shall consider the suitability of all other approved agencies.

Public health units presently administer 29, I believe, of the province's home care programs. They've done a good job and in some areas might well emerge as a natural community choice for an MSA. I believe that section 11(3) limits a community's ability and right to plan, and the city of Toronto strongly recommends that subsection 11(3) be struck from the act.

We note too that health promotion and wellness are not addressed in the legislation, which is a cause for concern. The government's implementation framework from 1993 made a commitment to incorporate wellness into all programs and services in the long-term care system, and the city recommends that health promotion be included as a key service under the current legislation and that multiservice agencies be required under the regs to develop and implement comprehensive wellness plans for the communities they serve.

Ms Beatrice Levis: Community-based reform of the long-term care service system has been on the seniors' agenda for many years. When some of us started out on that agenda, it was not a personal priority; now it has become that, too. Not that most seniors are not healthy, but the probabilities are now weighted a little more against us.

I want to say straight off that as welcome as this reform may be it will never work without sufficient funding. If seniors are to stay in their homes -- and that's where most of us want to stay -- we're going to need funding for all the community, personal and professional support services to make it possible. No less important are funds for family support groups, respite care and the expenses of informal care givers.

We need to see the government's plan for resourcing long-term care, and we want it to include adequate global funding for each MSA. As other parts of the health care system are reformed -- for example, as hospital stays are reduced -- we also want to be assured that those dollars will follow each person discharged into community care.

I just want to digress a minute. We have files that indicate that many elderly people discharged early from hospital have been at risk and that this has resulted either in death or in longer hospital acute care in the end. So we're very, very concerned about convalescent care being built into the long-term care system.

In this regard, we are particularly concerned that the regulations of the act could open the door to charging user fees. When regulations are being drafted, we urge the government to let consumers like us have our say. We have always said, and we intend to continue to say, loud and clear, no to user fees. We also want input to the regulations in order to protect other rights and interests, including the right to be on the boards of multiservice agencies in more than token proportions.

We endorse local accountability and recommend that the regulations require public records and open meetings of multiservice agencies as well as public input.

We want the government to set up a process for monitoring the four-year phase-in of MSAs to be sure that the new structures and services are flexible enough to serve the needs of consumers and the intent of the act.

We ask as well for some flexibility in the 20% ceiling on purchases of service by an individual MSA so that all needed services can be covered.

The appeal process in Bill 173 is confusing and appears to overlap with the workings of the Advocacy Commission. We ask the government to clarify the role of the Long-Term Care Act in relation to the Advocacy Act so that there is no confusion or duplication of function. Duplication is a luxury the long-term care service system simply can't afford.

In ending my remarks, I would like to express our support of the bill of rights, which strongly confirms consumer choice and dignity. We believe, however, that the bill of rights should begin with a clear statement of the fundamental right of all citizens of Ontario to access the long-term care service system and we ask that it be amended to include this statement.

Ms Elizabeth Amer: If I may refer members of the standing committee to the report of city council mentioned earlier by Dr Kendall, the report was passed recently by council and, as such, it is our official response to the current legislation. My remarks will colour in some of the content and recommendations of the report, but much more is contained in that document, more detail than I can cover here today.

I'd like to reinforce comments made by Bea Levis, in particular the need for adequate resources to carry out the reform. I think it's fair to say that much of the criticism of the proposed reform, criticism that's been heard before this committee, has grown out of the fear of giving up an imperfect system for an unknown system.

If consumers and service providers alike could be assured of sufficient global funding for each MSA to maintain current local resources and meet new needs, much of that fear and criticism, I believe, would disappear. But until those agencies and individuals get that assurance, it's reasonable to expect smaller agencies in particular to displace their fears about survival on to the multiservice concept itself.

Hence, I believe it's the responsibility of the government to clearly articulate a plan for funding long-term care that can sustain the system through the implementation phase and for many years to come.


A separate but related concern has to do with informal care givers, those extraordinary people, overworked, underrecognized -- women largely, in my experience -- who save us countless public dollars through selfless care giving. They don't need to have more responsibilities placed on them as a result of insufficient service funding. They do need our help; they need resources for respite care; they need support groups and essential materials and supplies. In this regard, I would request that the government listen to and act on the recommendations of the interministerial task force that is currently investigating compensation for informal care giving.

May I also draw your attention to recommendation 4 in the report of Toronto city council, that dental services for seniors be included in the professional services mandated under section 2(7) of the act. I should tell you that I say this with some passion, having a toothache as I talk to you this morning; entering my 56th year with a toothache, it certainly means a lot to me, that part of it.

As a city councillor, I'm very aware of how the present system fails the needs of shut-ins and recluses. I represent an area in downtown Toronto where isolation of seniors is really a serious problem, especially those who don't speak English or who speak very little English. I strongly support recommendation 5, to include funding for crisis intervention advocacy and follow-up programs.

Finally, I'd like to say how important we believe it is for multiservice agencies to function autonomously. Let me underscore recommendation 11 and say that we do not want section 52(2) of the act to be interpreted in regulation in any way that would undermine local autonomy and accountability.

Mr Jim Wilson (Simcoe West): Thank you, ladies and gentleman, for your presentation on behalf of public health in the city of Toronto. Councillor, I note that recommendation 4 in the city of Toronto report does ask that we include dental services under this act, professional services. When you're of age, I suppose, that might become of some help.

I should say, though, that I don't share the report's, and Dr Kendall's, comments. In particular, I don't share the optimism with respect to the flexibility that you see in this act. I'd ask you to take this opportunity to qualify a couple of statements on page 3 of the city of Toronto public health department report.

One of them, in the second-last paragraph, is, "The act would appear to provide a flexible framework for service delivery that makes it possible for a variety of service agencies approved under the act to maintain their identity and integrity within an improved system." I should just say I don't see that, and it seems to run contrary to well over 90% of the presentations we've had to date.

Perhaps you, as a member of the negotiating team, know something more than we do, but when 80% of the services after a four-year period have to be delivered by one agency called the MSA and when the VON and Red Cross and Saint Elizabeth visiting nurses and major organizations in this city and province tell us that they're out of business, when we've had discussions about the government buying the VON cars and paying severance for the nurses to become employees of the MSA, I don't see how they retain their identities. I'd like you to just comment on the flexibility that you see there.

Dr Kendall: When I looked at the framework of the act and when I looked at the work that preceded the act, it was clearly the intent that existing agencies could become part of, and maintain their identity of a logo, within a multiservice agency, and that was specifically designed to maintain their expertise and interest. I understand that for some agencies like the Red Cross their charter in fact would prohibit them from becoming part of a multiservice agency, but my answer to that would be that one could change one's charter if one wanted to continue to be in that business. But as they exist, and as one of their executive directors told us some two or three years ago, they are in the business of serving the public, and if another agency could serve the public and they couldn't change their charter, then the public got served.

Parenthetically, I think, the issue here is, from the data I've looked at, that Ontario spends more on long-term care and home care than any other province on a per capita basis or on an age-adjusted basis. Yet we have a system of services which is a lot less easy to access, a lot less continuous, a lot less accessible than many other provinces that spend 30% less than we do on a per capita basis. This is because we've chosen to build our system over 30 to 40 years on a number of distinct agencies and some larger agencies, and purchase of service.

If we are to direct that scarce funding to meet the needs of the populations we want to serve, we're going to have to do something about the current delivery of service. That I think, in some cases, will mean unbundling parts of services for direct delivery and will mean agencies coming together to work underneath a governance structure to eliminate duplication in administration, duplicate assessments etc. In some cases, I think that will happen to some agencies.

Mr Jim Wilson: We do have agreement, I think, among all parties that yes, the system needs to be better coordinated and people do need to come together, but first of all, I don't think the bill even preserves the logos of these local community agencies currently in existence, and preserving the logos wouldn't go far enough. When you're dealing with the Catholic Health Association of Ontario and many of the different religious and cultural agencies that we have out there, the logo is not what's important, it's the mission statement. All of those mission statements are to be absorbed into the multiservice agency, which we see as an arm's-length government agency that indeed will be monopolistic in terms of delivery of services.

The second thing is that you talk about multiservice agencies essentially in the next paragraph, "The act also appears to negate any perception that multiservice agencies will be overly bureaucratic, will reduce consumer choice or deliver service of inferior quality."

We are very much concerned about the bureaucratic nature of these. It has not been proven in the history of this province that bigger is better. In fact, the trend in business and the trend in many other governments now in North America, as you know, is to move towards smaller units of system delivery. We may be, with this bill, replacing several little agencies which, upon examination, actually are fairly efficient given that many of them just have an executive director and maybe a couple of staff and then hundreds of volunteers. We may be replacing that with a large bureaucratic multiservice agency with several departments that people will be shifted around to.

Certainly, our experience with regional government and other types of comings together of government bureaucratic institutions has, in my opinion, not proven to be the most efficient way to deliver services, and the public seems to want government to go in the opposite direction. Do you want to just comment on that sentence you have where you don't see any of that in this bill?

Dr Kendall: I think it would be perfectly possible to design a system that did have layers and layers of bureaucracy inherent in it. I'm actually confident in the abilities of the district health councils and the consumers and the service providers that sit on them to redesign a system that doesn't incorporate layers of bureaucracy and that is responsive, with local access points, and at the same time diminishes the amount of administration and overhead that currently exists in the large numbers of service deliverers and the brokerage system we currently have.

I base this on some knowledge of the local district health council planning process. I also base it on some experience from British Columbia, where they do have a much more integrated service delivery system. It works well and flexibly and responsively.

Mr Jim Wilson: I appreciate it. Mr Chairman, Mr Jackson would like a short question.

Mr Cameron Jackson (Burlington South): Ms Levis, I appreciated receiving your contribution to this brief. I'm concerned, and can only concur, that your fears are legitimate when you say that as long as there's the appropriate funding we can meet the assessed needs of seniors. You go on to suggest that there be no user fees, yet when I look at recommendation number 14 from this city of Toronto public health department brief that's been passed by city council, number 14 says, "That the government amend section 12(2) to allow MSA boards to provide optional services without the consent of the minister, so long as these services are not paid for out of public funds." I read that to indicate that they want further authority to charge user fees without consulting the minister. Is that how you read that, and could I get some feedback from you as someone whose interest in this is on behalf of consumers of these services?

Ms Levis: Yes. I think there is a difference between the type of services that one must receive in order to remain healthy and independent -- for instance, visiting by a nurse and that type of thing, or dental care, which is absolutely necessary -- and the kind of service which has to do with maybe getting the roof repaired or some other optional type of service which is required in order to maintain the home. I think the difference here is that 14 is not contradictory in the sense that what is being directed there are the kinds of services over and above those that are deemed necessary for maintenance of health and wellbeing.


Mr Jackson: Very briefly, Ms Levis, you realize that there are user fees built into the language of this bill and that there are user fees right put through the system currently. One of the concerns that has been expressed is that when we as a legislative body amended Bill 101, institutional care and long-term care reform, it resulted in $150 million to $160 million of increased user fees for residents. There are legitimate concerns when issues around user fees are raised.

Let me just put a fine point on this, and that has to do with the question my colleague, Mr Wilson, raised about how there's more to the logo of, say, the VON or Saint Elizabeth visiting nurses, when you consider that many of these agencies currently, and I always think of the Catholic agencies when this comes to mind, will take a person who, based on their needs, cannot afford the user fees that are riddled through our long-term care system currently and will occasionally say, "We'll pay those costs, we'll absorb those costs." I consider that as valuable as the potential loss of volunteers.

This isn't a debatable point. It's clear that we will lose those agencies being able to take those costs and absorb them on behalf of persons less capable of paying, and that would be a serious loss to this system. Have you given any consideration to, or done any examination of, those agencies that are currently insulating seniors from these additional costs that keep surfacing with great regularity in these reforms?

Ms Levis: The mayor's committee on aging itself has not done any investigation. We take the stand that studies have shown that user fees in general by government-operated programs are counterproductive and penalize those who need them the most. By the way, we did object to the increase in fees in institutions. It's part of our general approach that user fees are counterproductive, penalize those who can least afford it and result in more bureaucracy, not less.

Mr Jackson: Thank you very much, Ms Levis. We are entrenching in this legislation the fact that MSAs will not have the flexibility to say, "We're not going to charge fees to this group of citizens but charge fees there." That flexibility has been removed from this legislation. That is one of the things we were looking for. Again, my colleague Mr Wilson was trying to stress what was meant by flexibility, but on user fees we see this bill as having less flexibility to deal with those. We would commend you to monitoring that with us because we're very, very concerned about it for seniors in the province.

The Acting Chair: I wish we could continue, but time simply does not permit.

Dr Kendall: Could I make one very brief clarification? This is a report from the long-term care negotiating committee and not just from the department of public health, and that includes representatives from the board of health, the Toronto Mayor's Committee on Aging, the mayors committee and the neighbourhoods committee.

The Acting Chair: Thank you, Dr Kendall.


The Acting Chair: Our next presenter is Evelyn Fisher. Good morning, and welcome to the committee.

Ms Evelyn Fisher: I'm pleased to appear before you as a consumer of community health services. I would like to give you a few examples describing my involvement as a consumer and a volunteer in the community health service system.

Last summer, during a very serious illness, I was fortunate to be able to remain in my home with Saint Elizabeth visiting nurses monitoring my intravenous medication therapy. During that two-week period, the Saint Elizabeth nurses monitored my progress and response to treatment. The nurses visited me once every eight hours to administer my antibiotic therapy via a saline lock. The home care coordinator met me in the emergency department at Oshawa General Hospital and arranged to have Saint Elizabeth nurses provide my care because of their recognized expertise in infusion therapy in the area.

During the past four years, I have been a volunteer board member of Durham Region Community Care Association. My responsibilities included being the chair of the human resources committee. This not-for-profit organization provides community-based support services for the elderly and adults with physical disabilities. Durham Region Community Care was very proactive in the long-term care new direction discussions in the region.

My experience with VON occurred in the spring of 1992 during my placement as a management intern. This experience increased my knowledge and understanding of the role of the home care programs in arranging for home care services in the Durham region. At this time, I also became aware of the critical role that volunteers have in enhancing home and community programs and services.

My interest in long-term care further developed as a professor in the faculty of community and health services at Sheridan College. My involvement with all these organizations has kept me well informed of the Ontario government's goal to redirect long-term care and health services in a more comprehensive, accessible and fiscally responsible manner. Currently I am the consumer representative and chair of Saint Elizabeth Visiting Nurses Association Durham advisory committee. Today I will address my concerns with this proposed legislation as a consumer and as a stakeholder.

My concerns, first of all: The proposed MSA structure will be providing consumers like myself with a menu of services. However, we will not know what the ingredients are or the quality of the final product. We now have reasonable knowledge of the quality and end product of the programs and services provided by the existing not-for-profit community health services providers.

Because organizations such as Saint Elizabeth visiting nurses have a philosophy and a value system in place, their committed staff have provided consumers like myself with compassionate, holistic care. My case manager and her coworkers incorporated the critical biological, psychosocial, spiritual and environmental aspects into my plan. These nurses recognized the importance of addressing my self-esteem and sense of self during this crisis. The nurses became advocates on my behalf when the home care coordinator suggested that I do my own IV medication administration. These nurses were able to provide the home care supervisor with factual information of why this was not possible.

How will an agency which is both funder and provider be able to be an advocate for clients?

A major area of concern is the elimination of the current charitable provider organizations. In the proposed legislation, these current providers will be eliminated, with perhaps only 20% of services which will be contracted to selected provider organizations. The ultimate goal is to have the MSA provide 100% of services.

This proposed one-stop shopping is actually a monopoly. In the former Soviet Union, there were government-run department stores. However, the consumers were not provided with much selection. Healthy competition promotes innovation, flexibility and fiscal responsibility. My fear is that this competitive innovative spirit will be lost with the proposed MSA structure. The losers will be us, the consumers.


Another area of concern is the length of time from referral to an MSA, the assessment, determination of eligibility and provision of service. Who will be doing this assessment, a generic worker or an experienced professional, such as a nurse?

Maintaining the high quality of service as currently provided by existing agencies is a big concern. The staff in the current provider organizations have a history, an identity of who they are and they have developed positive relationships with their communities. This sense of identity stimulates strong commitment to an organization and the quality of services provided. These existing agencies also provide their staff with training and up-to-date education. How will the proposed MSA structure ensure that the staff are kept up to date with current knowledge, techniques and skills required in an ever-changing health and community service environment?

What will replace the current volunteers who so closely identify with those chosen organizations? I volunteered for Durham Region Community Care and Saint Elizabeth visiting nurses because their philosophy, values and goals fit with mine. Individuals volunteer for organizations for reasons similar to mine. It would be very difficult to volunteer for a government-mandated agency that had no history or identity and that is primarily a government agency.

In summary, the proposed legislation seems intent on burying the current charitable community health service provider organizations and the quality of services provided to us, the consumer. I am concerned, as a consumer, that the new proposed structure will limit my ability to make informed choices regarding services and the service provider.

The proposed legislation will create financial burdens on consumers for purchasing services if we do not meet the eligibility criteria.

A comprehensive review of long-term care certainly was needed, and the government did have stakeholders participate in the discussions. Consumers and other agencies did not anticipate that this would result in the dismantling of the existing provider agencies.

My recommendation is, fine-tune the wheel, don't reinvent it.

Mr Larry O'Connor (Durham-York): I appreciate you coming as a consumer of the services in Durham region. I'm a resident of Durham region. I live up in the north part of Durham region. We've got a small part of Durham Region Community Care that's reflected in Brock Good Neighbours. I wouldn't say my constituents in the north, through that agency, are given all the services that are more available in maybe some of the more populated parts of Durham region.

In fact, sometimes when you get an agency such as Durham Region Community Care that does all of it that's, as you say, near perfect -- you know; not quite -- we end up seeing bureaucratic decisions made like sending somebody all the way up to Cannington to clean the typewriter because somebody down in Whitby suggested it was time to get that done. That's not really, I think, good, efficient use of dollars for all the money that was spent for somebody to go up there and do that. We've got a coordinator up there who pulls together some of the services that are necessary, and I think that's an important role that needs to be played.

I think when we take a look at the continuum of care that is needed, we don't have a wheel that needs to be fine-tuned in every community. I think in some cases maybe it can be fine-tuned, and when you pull the community together and you involve everybody, we're going to end up with something that's going to be better than we have in place today. In some areas, it's going to require more work than others.

Consumer involvement is going to be a key to this change, because the important thing here is what is needed by the consumer, and it isn't necessarily going to happen by maintaining the multiplicity of agencies out there, and all the different administration costs that are reflected in that. What is necessary here is something that is going to grow from the community up, and I want to make sure that in my part of Durham region, whether you live in Gamebridge or whether you live in Uxbridge, you're going to have an opportunity to be involved in that. There are services provided there today, and I don't want to see any of my constituents that are needing those services as a consumer be denied.

In fact, I know there's been a lot of money that has gone into the community side of health care. It's something that is often overlooked by people when they reflect on the accomplishments of this government that there's been a 54% increase in the funding on the community side of long-term care. This year the total is going to reach $850 million, which is over $300 million more than what was there in 1990. The dollar commitment is there, and what we want to do is involve as much of the community as possible, from the volunteers right up, and we want everyone to be involved in that process.

I appreciate that you've been involved in it and I hope you continue to be involved in it. Maybe you can explain some of the role that you've played in working with the long-term care committee with the district health council to make sure that your role as a consumer reflects some of the needs of the consumers from the part of Durham region you come from.

Ms Fisher: My role was as a volunteer with Durham Region Community Care and currently with Saint Elizabeth. I was not involved with the district health council. There were people from these organizations that were involved.

I'd really like to take point on your talking about Brock region not getting the services that they want and the best way of dealing with this is by dismantling the current organizations so a new structure could be created. I really don't understand how that's going to be a cost-efficient way for the consumers in Brock to get services. Certainly they need services, but to say that we would dismantle what is already provided by the existing agencies I do not feel will address the problems of consumers in Brock or in Oshawa, where I live.

Mr O'Connor: The important thing here is not to try to dismantle everything that exists today but bring what exists today and pull together and involve the consumers so we can evolve so we make sure that the people up in the north part of Brock township have the same availability of services that are available to somebody who may live in another part of Durham region.

Ms Fisher: I don't understand how that relates to the MSA structure. I don't understand what you're trying to tell me. Are you trying to tell me the government is looking at that area, which it hasn't? I don't understand what your point is, sir.

Mr O'Connor: The point here is that not all parts of the province as a whole have been well served in the past in taking a look at all the services that are needed for the consumers of long-term care services. In Durham region, Brock Good Neighbours, up in Brock township, does do a very good job, and I'm sure the people who are involved in not only volunteering or working with that agency are going to be involved with the process that's going to see the change, so the consumers up in that area aren't going to be left in a lurch.

The important thing is that not all communities have received the same level of care that has been made available in parts of the province, and what we have to do is try to take a look at the needs of the consumer right across the province. What we have heard, unfortunately, is that the status quo is fine and we shouldn't really do anything about it. That's not what people have said for a lot of years: "Please don't do anything, please don't change anything. Everything is fine out there as far as the provision of long-term care within the community."

Ms Fisher: I think there are different ways of providing services for areas which don't have it. My concern, as a consumer and a stakeholder, is the process that's going to be set up to provide these services. My brief does not say that services needed to stay the way they were. My suggestion is that they be fine-tuned to make the old system work more efficiently.

The Acting Chair: Thank you for your presentation. We shall be taking a two-minute recess, or thereabouts, to properly prepare for our next presenters.

The committee recessed from 1021 to 1026.


The Acting Chair: I want to extend a welcome to representatives on behalf of the Citizens for Independence in Living and Breathing. Good morning.

Mrs Margaret Wagner: Good morning. My name is Margaret Wagner. The three of us, as you know, represent Citizens for Independence in Living and Breathing, which is a nationally incorporated charitable organization which assists ventilator users with neuromuscular disorders through education and information. First of all, we'd like to thank you very much for the opportunity to present our views to this standing committee. It is greatly appreciated.

In our brief, which I believe you have, there is a one-page introduction followed by a summary of key recommendations which we will use as we speak this morning. We will speak to the summary. Following the summary, there is a complete text of our brief, including our recommendations in detail. I will speak briefly to part 1 of the summary, which deals with the bill of rights.

First of all, we are delighted to see a consumers' bill of rights included in the act. We wholeheartedly endorse this. We would, however, like to make it stronger and we have three suggestions to do so.

(1) We support the addition of a clause to the bill of rights which would guarantee the right of access to community services for all consumers who meet eligibility requirements.

(2) While consumers or their agents are given an opportunity to participate fully in the development and revision of their plan of service, we believe this could be strengthened by also being made a right. In addition to the participation of the consumer in development and revision, we would like to see the consumer involved in the evaluation of the plan of service. We are aware that this is not a simple request because it would involve an addition to the bill of rights itself, a change to the definition of "plan of service," and, as well, a change to section 20. So we realize that is not necessarily a simple request, but it's still something that we believe in.

(3) We believe the bill of rights could be considerably strengthened if contravention of any part of the bill of rights was specifically included in the list of reasons stated for revocation or suspension of an agency as listed in part X.

I am now going to turn this over to the real experts who are here with me today, who will discuss the rest of the summary.

Mr Steve McPherson: My name is Steve McPherson. I use phrenic pacers for breathing 24 hours a day as a result of a diving accident 12 years ago. I spent nine years in institutions before moving into an SSLU about three and a half years ago.

I will address the first recommendation in part 2, which deals with the combined effects.

We are concerned about limited choices for minority groups such as long-term ventilator users as a result of rationalization by institutions and the development of MSAs. We are aware it is impossible for every MSA to include agencies that provide services for all groups, and there are an estimated 200 to 300 ventilator users in Ontario. Currently, respiratory centres that provide services to ventilator users are also few in number. We are concerned that the numbers will further be reduced as a result of limiting the centres providing services and that frequently the services provided by centres often reflect the philosophy of those in charge.

Our first recommendation in part 2 describes actions which we believe will maintain the type of services we need.

Mr Tom Wagner: My name is Tom Wagner. I have Duchenne muscular dystrophy and I have been a full-time ventilator user for 11 1/2 years. At this point, I can only breathe on my own for less than five minutes. Since being ventilated, I have lived at home with my family, partly by choice and partly because there is no other viable accommodation available to me. Living at home has made it possible for me to complete a bachelor of arts degree at York University.

I will discuss part 2, recommendations 2 and 3.

(2) The act requires that an MSA board reflect the diversity of the persons to be served by the agency. While there is mention of the disabled, there is no mention of consumers. Because disabled persons are not necessarily consumers of the MSA in their area, and because long-term ventilator users will not be able to obtain services at all MSAs, we believe the inclusion of the word "disabled" does not adequately ensure representation of long-term ventilator users on the boards of those MSAs providing services to them.

(3) The act restricts the information provided by any multiservice agency to "information about the services that the agency provides or arranges," and also restricts referrals made by multiservice agencies to "other services available in the geographic area for which the agency is designated." How do consumers who require unique services not available within their own geographic area learn what is available for them? How does a consumer requiring specialized services not available within his or her particular geographic area obtain referral to the appropriate agency in another geographic area?

Our recommendations for resolving these issues are listed on page 2 of the summary.

Mr McPherson: In our part 3 we're dealing with attendant care. The first issue is functions of attendant or personal support workers. My part again deals with recommendations 1 to 4 of the summary, which address this issue.

There are four types of services listed in the act, which appear to be mutually exclusive. Currently, attendants provide services mostly from two parts: homemaking services and personal support services. We have three questions, then, that we feel need to be addressed and resolved.

(1) Can services from these two lists, or any of the lists, be combined and performed by one individual? For example, can somebody help me prepare my breakfast in the morning, which would be listed under homemaking, feed me, which would be in the personal support services, and then tidy up? If not, it's going to add a lot of extra time to my care, waiting for an individual to come in and do their part.

(2) Will consumers who choose to arrange attendant services outside of an MSA be restricted if they apply to an MSA for other services such as shopping, banking etc?

(3) Will attendants or personal support workers be able to use the wording of the act to restrict their activities to those on the list if they should be unionized?

Our recommendations address solutions to these possible problems.

I'll hand it back over to Tom. Confusing, isn't it?

The Acting Chair: It's like watching a tennis match.

Mr Wagner: Recommendations 5 and 6 in part 3 both concern direct funding. While we acknowledge and endorse the direct funding pilot project currently being undertaken, we recognize in the wording of Bill 101 that this approach is by no means guaranteed past the initial project. Direct funding should be enshrined in the act.

We are concerned that persons who require more than 180 hours of attendant care funding per month are excluded from this pilot. Although I have successfully hired, trained and managed the payrolls of my own attendants for more than 11 years, I am not likely to be accepted for the direct funding pilot project due to this restriction. Our fear is that high-level-care ventilator users could be excluded from direct funding in the future. The only criteria for this method of funding should be the demonstrated ability to effectively manage the system.

Mr McPherson: Part 4 is levels of funding and accommodation. I will address our recommendations 1 and 2.

The act is silent on issues of funding for community support. Currently, significant discrepancies exist between the funding available for institutional support of ventilator users and that which is available for community support, and an even larger discrepancy for families providing care at home. This is of particular concern to long-term ventilator users, who frequently require more care than the average person with a disability.

The cost comparisons are pretty up to date. For ICU it's over $1 million a year. For long-term care and rehab, it's up over $200,000 a year. Where I live, in the SSLU, it's about $70,000 a year, and that's including the rent subsidy, the family benefits and everything else that is provided for me.

Home costs are not quite available, usually because unpaid family support makes up for the brunt of what Tom gets. A solution would be to enshrine principles of funding in the act as written in our recommendation 1, and that arbitrary caps be removed to avoid institutionalization if an extra, say, $10,000 a year provided for the agency where I live would avoid institutionalization, because obviously it's still going to be less expensive than making me move back to West Park Hospital.


Mr Wagner: I will discuss part 4, recommendations 3 through 5.

Some conditions which lead to the need for ventilation are progressive, ultimately leading to 24-hour ventilation and the inability of some to breathe unassisted even for a brief period of time, five minutes or less.

Two formulae for funding, referred to as "basic funding level" and "enhanced funding level," have been proposed. However, there is no mechanism for flexible bridging between these two formulae which would serve the needs of persons with progressive disorders who gradually need increased assistance.

Existing SSLUs in Ontario, to the best of our knowledge, are not designed to provide a rapid enough response time for emergency situations such as accidental disconnection of the tubing. Noble House in Vancouver is a model of suitable housing for high-level care ventilator users, where an emergency response time of 30 seconds has been achieved. The threat of reinstitutionalization remains a grave concern for several CILB members who are ventilator users.

On the other hand, families that care for ventilator users at home have unrealistic expectations placed on them, frequently to the detriment of everyone's health. There are no vacations or weekends off, and sleep disruption for those providing the care is very much the norm. We recommend that respite care include an annual vacation period, occasional weekends and rest several nights per week.

This concludes our presentation this morning.

Mrs Barbara Sullivan (Halton Centre): This is a very comprehensive brief and I know that all members of the committee really appreciate it. You've done an enormous amount of work, and we'll want to review it both inside this very short session that we have left as well as after.

If I can just flip through, I couldn't agree with you more on your recommendations with respect to the bill of rights, and we will be putting recommendations forward for amendment with respect to right of access to services by those people who meet eligibility requirements. One of the things we've been deeply concerned about with this bill is that the only right for service that's included is the right to be put on a waiting list. We feel that's not appropriate.

I'm also quite interested in and will want to look at your recommendation that contravention of any portion of the bill of rights would be added to the grounds for which the minister could revoke or suspend approval of an agency. I think it's an interesting one. Whether the revocation or suspension of the agency is the appropriate penalty or whether another penalty would be more appropriate, I think we should look at that quite carefully.

You've raised a number of questions, one of them with respect to the pilot project on the attendant care services. Here it is, on page 12. I did not know that persons who require more than 100 hours of funding at the basic level are excluded from the pilot project. I wonder if we could have a response from the parliamentary assistant or the ministry representative as to why that decision was made. Clearly, there are a number of people who require attendant care for more than that period of time. Why were they not included in the pilot?

Mr Wessenger: I'll ask Mr Quirt to reply to that question.

Mr Quirt: Our current thinking on the policy for attendant care outreach services delivered by the multiservice agency or by independently funded attendant care outreach programs -- disabled consumers have the choice as to whether they wish to have their attendant care outreach programs continue to be independently funded or whether they wish to access attendant care outreach services from the MSA. The current service limit I understand is 180 hours.

The point is well taken that in the case of some consumers, particularly those who use a ventilator, that 180 hours may not be an adequate upper level in order to provide the degree of emergency response and onsite service that's necessary.

I suspect that the pilot project will be looking at just that issue. We're hoping to learn from the pilot project under what circumstances that upper service level would have to be adjusted to accommodate as many people as possible in either the supportive housing settings that one of our presenters resides in or on an attendant care outreach basis, where the attendant care agency employs attendants to serve disabled consumers, or whether the disabled individual, the person with the disability, employs his own attendant or attendants.

Mrs Sullivan: I'm just quite taken aback at that. I did not know that the pilot was limited to the 100 hours. I certainly know of many --

Mr Wessenger: He said 180 hours.

Mrs Sullivan: No, 100 hours. The pilot is limited to 100 hours. The current rules are 180.

Mr Wessenger: I think Mr Quirt indicated that the limit was 180 hours. Is that correct?

Mr Quirt: It's my understanding that the limit is 180 hours and the pilot project is limited to 180 hours.

Mrs Wagner: The enhanced funding formula still states 180 hours but it suggests care by people with greater preparation and therefore with higher salaries. If you take that money and put it into attendant care, you could come in under that budget by using attendants for the hours required instead of RTs or RNs and so on. We're hoping that will be partly a solution, but it would certainly put the hours over 180.


Mrs Sullivan: I apologize for the confusion over the 100 hours.

I'm also very interested in the question that you ask on page 8 with respect to how consumers who require unique services that are not available within their own geographic area receive information about what is available and where, and how those services can be arranged. I think that issue, particular specialized services, does merit an amendment that makes it clear that the MSA's responsibilities go beyond the geographic area. I think we'll all want to look at the wording there.

I'd also like to have a comment from the parliamentary assistant with respect to an issue that you raise on page 11, item 3. The question is, "Will attendants or personal support workers be able to use the wording of the act to restrict their activities to those on the list," should they be unionized? I suppose that really what you're looking at here is a work-to-rule situation or a situation where there is a conflict in a bargaining dispute. I wonder if the ministry representatives could comment on the kinds of care, the kinds of services, whether it's through an MSA or through other health services, that cannot be withdrawn or limited and what impact the existing law has on people who are receiving care in their homes or in other community settings.

Mr Wessenger: I think perhaps the first answer would be that the matter would be determined by the provisions of any collective agreement and not by the act itself. I don't know whether legal counsel could add to that.

Ms Gail Czukar: With respect to your first question about what would restrict the activities of the worker, that would be determined by the collective agreement and not the wording of the act. I'm not sure if I heard the last part of your question about the effect of the existing law on services now being provided.

Mrs Sullivan: Certainly, we know that health care providers in hospitals and in other long-term care facilities can strike and can withdraw services and so on. What mechanisms are there to ensure that people who are at severe risk are not placed in jeopardy as a result of the withdrawal of services? We know that historically there has been a kind of cooperation, I suppose, usually in those situations in hospitals and facilities, but I don't know that we've been exposed to that kind of work disruption in home care or community services.

Ms Czukar: We have had strikes and other labour action in other kinds of services. I guess there would be two mechanisms. One would be the use of the Hospital Labour Disputes Arbitration Act that could be applied to services such as these, or to have them classified as essential services so that arbitration would replace the right to strike. We haven't discussed that at all, but those would be two mechanisms that would ensure that services would carry on in the event of labour disruption for people who absolutely needed them.

Mrs Sullivan: Could we just ask that the ministry give some thought to these situations in the community setting?

The Chair (Mr Charles Beer): Do you want to comment?

Mrs Wagner: I sat on the committee that looked at the education. That's how we are involved in that. If the personal support worker sees a list in the law that says "personal support services," is the personal support worker going to say, "That is my job description or refers to my job description"?

The Chair: I think the issue has been raised and the minister will look at that.

As Chair, and I've come in late and I apologize for being late for your presentation, I also at times have to play the heavy, which means I have to say that discussion will have to end because we have other presenters. But I know that on behalf of the committee we want to thank you for coming, and if I may just say, Steve, it's good to see you.

Mr McPherson: I love it where I am.

The Chair: We wish you all the very best with your work ahead. Thank you for coming before the committee.


The Chair: Our next presenters will be from the Association of Ontario Health Centres.

Ms Sonny Arrojado: I'm Sonny Arrojado. I'm the executive director of the Association of Ontario Health Centres. The Association of Ontario Health Centres thanks you for the opportunity to present our position paper on Bill 173. You have a copy of our presentation and some additional information on the association and community health centres. As noted in the information that we have provided, we are the provincial organization of Ontario's community health centres and some health service organizations.

Our member centres provide support to approximately 200,000 Ontarians through programs and services in primary health services, health promotion, illness prevention, counselling, literacy, housing and employment. The activities currently undertaken by CHCs in health promotion, community development and advocacy to other communities are considered to be among those on the cutting edge of innovation and creativity. CHCs provide a variety of services to underserviced communities which, due to a variety of barriers which include geographic, cultural and linguistic barriers, need improved access.

You have in the information we have provided the beliefs and principles that are the foundation of what we are as a movement. We believe that equity in health implies equal opportunity to achieve and maintain health, including access to programs and services. It is this belief that guides us in our response to Bill 173.

As such, we believe that passed in its current form, Bill 173 will negatively affect access to programs and services, thus affecting the fundamental resources for health of Ontarians. AOHC generally supports the reform of the long-term care services and the attempt to implement reform through Bill 173. However, we believe that certain sections erode the overall merits of the bill. Our concerns are in the following areas.

The need for an integrated approach to health and social services: Bill 173 outlines service standards for Ontario's long-term care services but fails to incorporate the concept of wellness as a key principle of long-term care reform. For example, part I talks about simplifying and improving access through the continuum of community services, yet part II identifies specific service distinctions, which reinforces a fragmented approach to service delivery.

We firmly believe that an integration of the concept of wellness in the legislative framework of long-term care services would allow service provision to consider not only consumer needs but also consumer capacities for health. This, we believe, would provide a different way of looking at the role of the consumer and would help us develop a truly reformed approach to service delivery.

Because of this, we recommend that part II be amended to provide for an integrated approach to health and social service delivery.

Another concern is the need for stronger community participation. Bill 173 hints at a stronger role for the consumer and the community, but on closer scrutiny its provisions are rather weak in the implementation of this objective. For example, section 20, in part VII of the bill, provides an opportunity for the clients' participation in their "plan of service," but the section is silent on the role of the community as a whole in the process, other than by representation on the board. A variety of community activities influences the health and social wellbeing of individuals in their communities through partnerships with a variety of community agencies, and as such, the capacity of communities to help themselves must be recognized in the provisions of Bill 173.

Because of this, we recommend that section 20, part VII, be amended to reflect a stronger commitment to community participation.

Our next concern deals with the need for recognition of the value of volunteerism. Bill 173 lacks an appropriate recognition of the value and role of volunteers in long-term service delivery. We believe that communities have the right to service that is respectful, relevant and effective, including the use of local volunteer experience to respond to local needs.

We further believe that any legislation that provides for community service delivery needs to acknowledge and emphasize and support the value of volunteerism. Community service delivery must ensure an appropriate balance between the role of paid and non-paid health providers. Community service that draws upon the experience and expertise gained by volunteers encourages the community to build upon its capacities to help itself.


Therefore, we recommend that Bill 173 be amended to acknowledge the key role of volunteers in community service delivery.

We also see the need for recognition of the community agency role in local management. We have serious concerns regarding the prescriptive nature of certain provisions in the legislation. Like any number of services provided to the community, long-term care services can only be truly effective if they not only build on the needs and capacities of communities but acknowledge the legitimate role of community agencies in management at the local level. Government should set the broad parameters for the delivery of long-term care services, but it must not attempt to manage at the local level.

For example, part IX stipulates the appeals process in the event of consumer disagreement with the local MSA's decision regarding access, type and volume of service. The only level of appeal available bypasses the local MSA, the local DHC and goes directly to a provincial appeal board. The appeal process and structure contained in Bill 173 not only take the accountability from the local level, but also eliminate the capacities of local agencies to be responsive in a timely manner.

Another example can be found in section 56, part XI, which stipulates the powers of the Lieutenant Governor in Council to include the governance and management of a number of operational issues within approved agencies. In addition, paragraph 24 indicates that quality management systems would be centrally controlled instead of being the responsibility of the individual MSA.

Another example along these lines can be found in section 62, part XII, dealing with the functions of the DHC. I'm sure you have that laid out in your copies of the legislation. The way it is laid out, in our opinion, confirms the planning and advisory role of district health councils. As written, however, clause (d) allows, should the minister see fit, the assignment of a management role to DHCs.

We have concerns regarding the notion of DHCs being involved in management at the local level. DHCs are designed and resourced as planning and advisory bodies and should not have a management role. We are opposed to layers of management structures which are costly, not necessarily effective and will undermine the authority of local agencies in addressing local needs and concerns.

We therefore recommend that part X and section 56 in part XI be amended to include a community consultation process prior to the ministerial decision for revocation or takeover. We further recommend that part IX be amended to ensure greater community control and that subsection 62(1) be amended by deleting clause 8.1(4)(d).

We're also concerned with the need for a balanced approach to service delivery. Part III of the bill outlines a bill of rights for the consumer but fails to acknowledge the broad policy and financial context which dictate the extent service delivery can be provided. Consumer rights as noted in Bill 173 can readily raise expectations to a level that is not achievable and cannot be ensured by the service provider.

Subsection 3(1), part III, places a mandatory onus on the service provider to ensure that specific rights and specific conditions for service delivery are provided to the consumer. The capacity of the service provider to meet the conditions as set out in this section is directly related to the availability and level of funding.

At the operational level, an unqualified bill of rights could easily evolve as a barrier to a collaborative approach in service delivery. As currently written, subsection 3(1), part III, undermines the possibility of a mutually workable partnership between consumers and providers. This section needs to be amended to provide for a balance between what consumers can and should expect and what providers can reasonably deliver.

We therefore recommend that part III be amended by providing qualifications on the extent of services that can be ensured by the health provider.

Finally, we see a need for flexibility in legislation. We are strongly opposed to an approach that inherently eliminates flexibility in the delivery systems at the local level. Bill 173 is full of provisions which either imply or stipulate centralized control. For example, section 13 of part VI imposes limits on the amount an MSA can purchase community services to no more than 20%: limits on purchase of homemaking services, no more than 20%; limits on the purchase of personal support services, no more than 20%; and limits on the purchase of professional services, no more than 20%.

The provisions of the bill must be amended to provide local management with the responsibility and authority needed to respond to the local situation. The capacity of consumers and providers to develop and implement an appropriate service plan, as they see fit, must not be subsumed by government. We recommend that flexibility be integrated into the provisions of the bill.

In conclusion, we believe that the role of the community needs to be acknowledged and valued in any reform initiative. The bill must be amended to clearly delineate those areas that are controlled locally, those controlled regionally and those controlled at the provincial level. Any model of service delivery used in long-term care services must satisfy broad parameters set by government but flexible enough to adapt to the local situation and preserve those community structures that allow for effective management. Ontario's community health centre model, funded through the community health branch, is an excellent example of such a model. Indeed, where it seems it may fit with the local situation, the CHC may be the best vehicle for MSA designation in that particular area.

On the whole, and at the very least, the reform process must result in improved accessibility, quality of service, cost-effectiveness and improved accountability to the clients, the community and government.

We strongly urge the standing committee on social development to seriously consider our recommendations, which we believe will ensure that the legislative structure and framework for long-term care services provide a balance that would allow both consumers and providers a true partnership in the delivery of services within the context of a provincial framework.

Mr Jackson: Thank you for your presentation. I guess I can express on behalf of all the committee members that for those of us who have visited a community health centre, they're quite innovative and wonderful organizations, so we're rather intrigued at how they're going to comfortably fit within this MSA structure.

Before I get into some specifics, do you have some fears that in fact services that you're currently providing would be deemed by the MSA to be more appropriately provided outside of the community health centre? That's my first fundamental question. And if you do have some of those fears, could you give us an example of a kind of a service, because I do know you have quite an integrated, flexible model, you're very much on the leading edge of health promotion, and the bill doesn't really clarify that.

Ms Arrojado: We have those fears. I don't know that I can give you a specific example of that because each community health centre has a variety of programs according to the needs of their community. But our main fear is that, if implemented, the process of MSA designation and type of services that will be delivered will fragment the approach to health service delivery that should be integrated at the local level. We see CHCs working closely with an MSA, or acting as an MSA if it makes sense in that particular area, with the objective of ensuring that the approach, a singular comprehensive approach, is available at the local level.

I think, because of our concerns about what reform will look like, not only in long-term care services but in the health system as a whole, our fears are based on lack of an overall picture, which I guess the community is going to expect in the next few years, if in fact reform does take place, when and if it takes place. That is why any particular threat is something that really worries those communities.


Mr Jackson: I know you're speaking for all health service organizations in Ontario, but clearly when we were in northern Ontario, not only when we were doing bill 101 on institutional reform, but also recently, this summer, there were some very strong presentations on health centres in northern Ontario where they were servicing almost as large a model as the potential MSA in terms of geography and in terms of outreach. I think it would be rather inappropriate to disrupt that, since this is being developed in those areas, which is different from, say, downtown Toronto where they may form a portion of an MSA and not in the same catchment area.

Are you aware of any of your organizations which are actively involved in long-term care committees and are looking at making recommendations to the government about integrating the services; in other words, taking all the best elements of a community health centre and applying it to the MSA model? Can you point us in the direction of where this may be occurring somewhere in the province before this becomes law?

Ms Arrojado: We have some of the very active community health centres, for example, the Lakeshore Area Multi-Service Project. They've been involved in the subcommittee at the Metro Toronto district health council, and I believe had a report specific to where they see the MSA model would fit into the scheme of things.

There's a group of community health centres in Ottawa that have made, I believe, a representation to this committee concerning where they see the role is for community health centres in terms of integrating a service delivery approach. I think the main concern is that a model is designed provincially and intended to be replicated throughout the province, and in fact is not dealing with the needs at the local level, and in fact is really a very outdated approach to health service delivery.

It is replicating a system that we know to be expensive and not effective and not working with the community to work on their capacity to help themselves. Our concern is that if you only start to focus on needs rather than on the assets of the community, we will develop a system that will be outdated before it's even implemented.

Reform, in our opinion, needs to really change the concepts by which it looks at service delivery. It's not doing to people, but doing with people; not doing for somebody, but doing with somebody. It's very difficult to do this in the lack of a community development approach to reform. There has been a glaring and appalling lack of recognition for the need of community development in terms of any reform initiative, not only in this province, but right across Canada, and it's unfortunate and that's a real critical link. In our opinion, you cannot accomplish reform without that piece.

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


The Chair: I call on Mrs Margaret Myers. I note you come from MacTier.

Mrs Margaret Myers: I come from a little further than MacTier. That's the post office box I maintain.

The Chair: We are pleased that you have been able to come down and meet with us today. We have a copy of your submission before us, so please go ahead.

Mrs Myers: Thank you for having me appear here. I'm Margaret Myers. I am a resident of the township of the Archipelago, which is in the district of Parry Sound. I am prefacing my submission with two points:

(1) If the purpose of Bill 173 is, as it appears to be, a serious intent to provide all resident citizens of Ontario with access to community-based long-term care, I am asking this committee to clearly word the legislation identifying the level of government responsible for ensuring conformity with the act, or,

(2) If, as a result of these hearings, this committee decides to adopt a less all-encompassing program that would empower a municipality to fit the legislation to its own particular will, as suggested by Mr Wilson, a member of your committee, I am asking that the wording of the legislation clearly indicate this fact and leave nothing to individual interpretation.

Since the persons to be served by Bill 173 will be at a disadvantage either as to age, physical disability or illness, (1) would eliminate the need for costly litigation to enforce the provisions of the statute, as seems to be required in the case of other municipal services, and (2) would ensure that no misunderstanding could arise resulting in wrong long-term residential decisions on the part of individuals.

The purposes of this act as set out in part I are admirable in the course that has been set to deinstitutionalize our society for a future with an aging population. Congratulations are in order to all concerned for translating farsighted philosophies into a legislative instrument.

The act may possibly be flawed in an area that would probably never occur to the formulators of the policies. That is the area which requires other government agencies at various levels to fulfil what appear to be their statutory obligations in order that the requirements of Bill 173 may be met.

My husband and I, now reaching an age where farsightedness would indicate the possibility of being in need of some of the services provided for in this act, live in a municipality which refuses to fulfil the statutory requirements with regard to winter maintenance of the road under its jurisdiction, the only road access to our home, which is located in an R1 residential zone under the Planning Act, and furthermore will not allow us, under threat of prosecution, to winter-maintain it at our own expense.

This lack of winter-serviced road already denies us ambulance service for up to six months of the year since regulations allow only to the "end of a serviced road" as well as other in-home services already available. It can readily be seen that all future in-home support services in Bill 173 would be similarly affected.

Of much greater concern is the content of part II, "Interpretation," that includes "a municipality" in many of the definitions. This could possibly put an instrument in the hands of a power-wielding municipal council and/or employees, out of concern for their employment, to have residents removed from their home if it, a municipality, is not willing to fulfil the requirements of the act. My husband and I are optimistic of the prospect of not having to need these services but are realistic enough to envision the possibility and what it could mean to us, given the philosophies of the second-home-dominated nature of the municipality in which we live.

The act, to my mind, is meaningless for us unless it has built into it who will enforce the provisions contained. Aspects of the situation with regard to our road are covered in many provincial statutes but it appears that we have to shoulder the burden of bringing the issue before the courts. We are financially and emotionally drained in the attempt to have the levels of government involved assume some of the responsibility. How would we deal with a similar situation with regard to this act, 10 or 20 years from now, together or one of us alone?

The Commission on Planning and Development Reform in Ontario, the Sewell commission, in its final report, Summary and Recommendations: New Planning for Ontario, on page 3 recognizes that cottage country is "one area of Ontario that expects continued growth.... As well, more and more cottages are becoming year-round homes."

I would like to respectfully suggest to this committee that if a municipality zones an area as R1 residential, when there are provisions under the Planning Act to do otherwise, this is an indication that they are promoting year-round dwelling in such areas with the full recognition and acknowledgement of the obligations it imposes and ask that your legislation, Bill 173, provide for this.

Thank you or this opportunity to put my concerns and views forward.


Ms Carter: Thank you very much. It's interesting, we've heard from a very large number of people on this committee and yet there's always another angle and I think yours is a new angle that we haven't quite heard before. So I thank you for your general support of the bill and I hope that you and your husband will not need the services, but on the other hand --

Mrs Myers: I hope so too.

Ms Carter: -- you're wise to be concerned, as we all are.

I think what you're concerned about is the structure of how this is going to work and who's going to be responsible. I guess the general picture is that each multiservice agency will have funding, a sort of envelope from the government which they will then spend according to the priorities of that particular organization. They will be self-governing. Each multiservice agency will have a board which will be locally elected by, I guess, interested people who join so that they will be responsible themselves for what they do.

You brought in the municipality, and it is an interesting feature of the legislation that local health units in municipalities are designated as being low on the priority list of those who can become multiservice agencies. We have heard from some presenters who think that's unnecessary and should not be the case and that those agencies should be able to compete at the same level as other organizations to actually be the MSA. You seem to be expressing some fears that that might lead to problems, I guess because you've have problems with your own municipality. Perhaps you could comment further on that angle.

Mrs Myers: I have to admit, Ms Carter, that I read through this Bill 173 from beginning to end. I do not have the expertise since I've had no contact in my life with any support services. What I don't see in this bill is any wording that tells me that if this agency -- under the definition some of the agencies are the municipality -- says, "We are not prepared to do that, Mrs Myers," I have access to enforcement other than what already exists in other legislation in other ministries. It has been my experience that in order to enforce this, because it isn't specifically written into the act and it's covered by different sections of different acts, the only judgement that can be made is by the courts.

What I'm asking you to do is, if your intent is that every citizen have this access, then please have your consultants, your lawyers, whatever, look at it and say, "In this specific instance, how would we deal with it?" I see a situation where there's a three-week period or whatever to do with appeals, but we have been attempting to deal with our own situation for seven years directly. We have had it for nine years.

Authoritative agencies do tend to support one another -- and I don't disagree with that. This is the fabric of our society. We can't have one government agency fighting with another. Certainly we can't have the province fighting with its children, its municipalities and back and forth, but by the same token there is no point in wording legislation if you do not build this in in the first place, and I see that flaw.

Ms Carter: I think there are some safeguards here; one is that there is an appeals process. As I say, it is locally governed so that you would have access to the relevant board. Also, of course, we have the Advocacy Act kicking in probably early next year. I don't know whether you know about that.

Mrs Myers: No.

Ms Carter: That means that if you are a vulnerable person -- and as you so rightly said, if you need these services, you probably are a vulnerable person in some respect -- all you need to do is to call a phone number, which will be displayed in relevant places, and an advocate will come and see you.

Mrs Myers: Thank you.

Ms Carter: You put your own point of view, your problem. They don't tell you what you ought to do. They listen to you and they take steps to remedy what that problem is, either at the personal level or there's also what we call systemic advocacy, where if it's something that maybe affects a whole number of people because there's something wrong with the way things are being run or whatever, then that also can be looked at.

But maybe we should ask for an expert opinion as to exactly what the safeguards are. As I say, I think I've mentioned a couple of them, but perhaps we could have an expert opinion on what the safeguards are in this bill.

The Chair: Parliamentary assistant.

Mr Wessenger: What particular safeguards area are you looking at with respect to the question?

Ms Carter: As I say, the presenter is justly worried as to what will happen if we've got all this wonderful stuff in this bill and then somehow it doesn't work for her in her specific situation and what the comeback is.

Mr Wessenger: I think the concern that the presenter has raised is with the whole question of access. This bill doesn't really deal with the question of road transport access, and I think that's a matter that has to be dealt with relating to the Ministry of Municipal Affairs. I certainly have great sympathy for the presenter. I was quite interested in her comments that the municipality would not even let her maintain the road itself, because I have a second residence in another municipality, and one of the affluent owners of one of the summer homes maintains it in the winter by having it plowed at his own expense, and it is a public road. This is, by the way, in Muskoka.

Mrs Myers: Of course I'm aware, and it's the same in Huntsville. Every other municipality in the district of Parry Sound, of which our municipality is not the largest in population but the largest in mass and also the largest in assessment, allows citizens, under their inspection, to plow the road access to their property. Of course this is understood. We're not expecting the municipality or its taxpayers to absorb the cost; we are quite willing to do it ourselves.

Mr Wessenger: But your municipality won't?

Mrs Myers: Will not.

Mr Wessenger: Will not. I must say I also tend to agree with your position, and I think that legally if a municipality zones an area for full-time residence, under its zoning bylaw it has an obligation to provide access year-round. Probably the courts would find that, but I can understand your frustration.

Mrs Myers: I'm sure, but who can shoulder the financial burden?

Mr Wessenger: I think the point you've made is that there are impediments to services that governments provide outside of the area, and we ought to be looking at that aspect.

Mrs Myers: Exactly.

Mr Wessenger: I appreciate your comments in that regard.

Mrs Myers: Yes, and not necessarily for ourselves, obviously by the time this gets going, but to ensure that you don't get yourself into a situation that you hadn't foreseen.

Ms Carter: But then you would have the multiservice agency presumably on your side, because it would be trying to deliver services to you, and it could go to the municipality and say, "Well, look, we need to get to these people and we can't."

Mrs Myers: Oh, I agree. My concern was that sometimes the municipality may be the agency. That was my understanding of the definition.

Ms Carter: Which, as I say, is an interesting light on the fact that municipalities are not seen as the ideal agency.

Mrs Myers: I agree 100%.

The Chair: I think you have placed a broader issue by using your own specific situation. As Ms Carter said, at times as we get to the end of committee hearings we think we've heard all the different issues that might arise, and then something quite new emerges. We thank you for coming before the committee and making those concerns known to us.

Mrs Myers: I hope it has been of some assistance.



The Chair: I call on the representatives from the Durham, Metropolitan Toronto, Peel, Simcoe and York region branches of the VON. Welcome to the committee.

Ms Marg Purkis: Mr Chairman and members of the committee, we are pleased to appear before you today to present the views of five branches of the Victorian Order of Nurses regarding the government's legislation to establish multiservice agencies. My name is Marg Purkis. I'm a member of the board of VON, Metro Toronto. I am also a past president of the board of VON (Ontario) and am currently a sitting member of the board of directors of VON Canada.

With me today are Phil Curtis from VON, Durham region, president of their board of directors; Charles Style, VON, Simcoe county, board of directors; and Carole Burtch-Rudderham, who is executive director of VON, Peel region.

In 1993-94 our five branches provided almost one million nursing visits and 24,000 volunteer hours of service. We employ 1,100 staff and have 635 volunteers in our combined branches. We provide our services in a culturally sensitive manner and are responsive to diverse ethnic needs. A fact sheet appended to this submission lists the various programs and services we provide in and around the greater Toronto area at our five branches: Durham region, Metro Toronto, Peel region, Simcoe county and York region.

We at VON have long recognized that changes are required in the delivery of long-term care services. We applaud the government's commitment to strengthening the long-term care system and appreciate the hard work that has gone into developing new legislation aimed at improving service delivery. Specifically, we support the purpose and general direction of the act, the inclusion of a proposed bill of rights for persons receiving services, simplified access for the consumer, centralized information and referral, a mandatory quality management system, the introduction of appeal mechanisms, a partnership of health and social service providers, the emphasis placed on health promotion and wellbeing, and the improved availability of and eligibility for long-term care services.

We do, however, have a number of specific concerns about that proposed legislation, and I would like at this point to call on Charles Style from our Simcoe branch to begin to outline those to you.

Mr Charles Style: Our specific concerns are as follows:

(1) The erosion of our volunteer base: Our five branches are fortunate to have more than 635 volunteers who provide approximately 24,000 hours of service. Our volunteers give freely of their time to govern our agencies, fund-raise to support our charitable activities and, finally, provide service to many of our clients.

Our volunteers strongly identify with the VON. The act appears to assume that these volunteers will shift their support to a proposed MSA and, in essence, their role will simply continue under a new service-provider arrangement. We challenge this assumption; I personally, as a volunteer for VON for 15 years, challenge this assumption. We strongly believe that volunteers such as ours will not transfer their loyalty to an MSA.

When the home care program in Metro Toronto attempted to establish a volunteer program some years ago, it found that volunteers were not interested in lending their support to a government agency. A few volunteers might be willing to sit on an MSA board or its committees, but they will not fund-raise on its behalf, nor are they likely to provide much-needed services to clients. If well-established, highly respected organizations such as the VON disappear, so too will many of our volunteers. These volunteers and our established volunteer programs may be lost for ever to the long-term care system and the clients within that system.

(2) Protection for our employees: Although staff in some of our branches are unionized, in others they are not. We understand that unionized employees will have the first opportunity for available jobs in the MSAs. Our chief concern is the continued delivery of quality community care by experienced staff trained in the community, regardless of union affiliation. Non-unionized staff are entitled to fair and equitable treatment under the proposed legislation. Staff who are not currently unionized must be given full protection similar to that offered to unionized employees.

(3) Organizational identity: For many people, community and in-home nursing and the VON are synonymous. Our nurses have operated at the grass roots, shaping our services to meet community needs and providing leadership and innovation in the delivery of community health and health-related services. An intention of the legislation is to streamline the service-delivery system. Such a goal is achievable while retaining the expertise, commitment and resources currently in place. Any change needs to be based upon research and demonstrated results rather than simply for the sake of change. Are you prepared to explain to the public why organizations like VON are being driven out of existence?

(4) Our charitable activities will not be sustainable: At present, the majority of our program revenues come from a fee-for-service arrangement from government contracts. Donations are used to augment these and volunteer programs, to develop new, unfunded services and sustain our charitable work. The infrastructure that we have in place to support our visiting nursing program, along with our volunteers, makes many of these activities possible. However, the new model of service delivery will dismantle this critical mass and make it more difficult to introduce and sustain new services. How will such activity be continued and by whom? Does the government no longer see a need for charitable services in health care?

Mr Phil Curtis: (5) Supporting responsiveness to client, not service complacency: The proposed MSA concept includes the direct provision of services, such as nursing, by each MSA. We are not the first group at these hearings to question the wisdom of integrating direct service delivery with other MSA functions, such as referral, coordination and financing. Our concern is that such a model of service delivery will not ensure responsive, cost-effective, quality service delivery. It has been argued that service monopolies invite complacency and tend to be costly and unresponsive to consumer needs.

In Canada, no long-term studies have been conducted to demonstrate the effectiveness of the integrated service delivery model proposed in the new legislation. Moreover, the proposed MSA model has not been subject to any pilot studies in Ontario. The legislation proposes a different way in which to deliver services. We strongly recommend that one or two pilot projects be undertaken and the results evaluated before implementing the MSA concept throughout Ontario.

Consumers should not be expected to take a leap of faith and hope that the proposed new system will offer any significant improvement in service delivery. Structural change in the provision of health and human services requires field testing, evaluation and refinements prior to full implementation. Our branches have the necessary expertise and knowledge and would be pleased to participate in any pilot projects. We have always welcomed the opportunity to be responsive to client needs.


(6) Other impacts on cost and quality: The proposed legislation was designed to reduce the bewildering array of small agencies providing similar services, each with its own overhead costs. The implementation of MSAs will address this concern for some types of services, but the same cannot be said for nursing services.

For example, in Metro Toronto there are currently approximately 20 groups planning for MSAs. Presumably, each will provide nursing services. At present, VON and Saint Elizabeth Visiting Nurses' Association provide a minimum of 90% of the home care nursing within our catchment areas. Will the integration of nursing into approximately 20 MSAs reduce the administrative costs for a nursing program in these MSAs? We think not. In our own experience, a nursing program needs an infrastructure including education and training, supervision, scheduling, quality management programs and so on. In the present system, the government has nursing service cost data under home care, but costs of the proposed new system are unknown.

In this regard, we support the argument put forward at these hearings by our colleagues from Saint Elizabeth Visiting Nurses' Association. According to their research, if the nursing services provided in Metro Toronto at this time are offered by, say, 20 individual MSAs, additional expenditures of at least $7 million per year will be required to sustain the current level of service. Does this not defeat the legislation's intention to reduce the current overhead costs of service providers?

This argument also brings us to the issue of quality. Evidence exists to demonstrate the relationship between service volumes and quality outcomes. A precondition for quality care is that sufficient volumes exist to give nursing professionals continued exposure to skilled procedures in order to maintain their competency. Critical mass, therefore, helps to ensure the maintenance and evolution of high standards and practices. Will each MSA have the critical mass to maintain nursing skills?

VON has policies, procedures, standards and quality management initiatives implemented province-wide. Our branches also have a well-developed network to address educational issues, new standards, to share information and design new systems that lead to the improved delivery of care. Will standards be developed and maintained? At a minimum, our five branches expect a total of 25 to 30 MSAs. We believe that the direct provision of nursing services within each MSA will result in higher costs and potential risk to quality and to standards.

(7) De-insuring implied and the potential for a two-tiered system: We understand that the government has proposed the introduction of a funding envelope for each MSA. Each MSA would determine its own spending priorities. The intention to leave budget allocations up to each MSA is particularly troubling. No safeguards or clear guidelines for health and social service allocation have been developed. Without these, waiting lists for some services will grow. Clients whose needs cannot be met because of capping will have to look elsewhere for service. Those who can pay for it will seek other options for service. Those who cannot pay will be out of luck because charitable agencies like VON will no longer have the capacity to provide charitable services to the extent we do now.

At a time when hospitals are shifting more and more of their workload out into the community, there is already a shortfall of dollars to support home care nursing and other health care services. We have been assured that new dollars are going into the long-term care system. Significant funds have already gone into increased support for homemaking, long-term care facilities, placement coordination and all the costs associated with developing the MSA concept. Even more dollars are apparently earmarked for labour adjustments and training. However, more new dollars will be required to create a totally new system. Can we be assured that this structural change is possible, financially feasible and in fact desirable?

Our final concern is the built-in rigidity. The rigidity of the act, proposing a 20% budgetary limit on purchased services and a four-year horizon, prevents local planning and development of MSAs specific to community needs.

Ms Purkis: Our recommendations are as follows:

Build on strengths. We have always been here for the clients we serve when governments are unable or unwilling to provide services. Rather than tearing down or dismantling charitable, not-for-profit community health agencies, build on the strengths of existing health care providers.

Promote more flexible legislation. Eliminate the 20% budgetary limit and the four-year time frame, and thus support local planning.

Focus on functional integration and a partnership model. Focus resources on promoting a partnership of health and social services providers. VON proposes that an appropriate beginning to a multiservice agency be the formation of a partnership of long-term care health and social service community agencies committed to working together towards the stated objectives of long-term care reform. This partnership would include the establishment of an advisory committee that meets the recommended composition of the board of directors as described in the act. This committee would provide the connection between agencies and their respective boards of directors in an advisory rather than in a governing role.

Such a model could ensure effectiveness in terms of cost, service and quality through well-developed management information systems and common data standards. Such a model would build in evaluation, monitoring and measurement on quality management indicators. In evolving such a model and promoting the user-friendly service delivery system, the VON recommends the following:

-- First, allocating dollars to the development of an integrated information system with service provider access to a common database.

-- Promoting the use of a common client chart.

-- Establishing area-wide electronic networks.

-- Providing technology such as 1-800 numbers to support consumer access through a single point of entry. As a matter of interest, this is a program that is currently in use in the York region. Carole, perhaps you could just briefly describe how that is in place.

Ms Carole Burtch-Rudderham: In York region, they've begun a partnership of community and health services, and it's just an example of how agencies can work together in the community. There's a 1-800 number, and this is located in the home care office. Any agency that receives a phone call for information takes down all the information the client is asking about and faxes this information to the appropriate agency. Then the appropriate agency calls back the client, and in this way the client only has to answer the questions once. All the agencies guarantee that some kind of phone call will be returned to the client within 24 hours.

They also had a small survey done in York region. All the agencies involved, which are Alzheimer's, home care, VON, Community Home Assistance to Seniors, or CHATS, and Red Cross, did this survey over four weeks. They watched all the incoming calls and asked how many times a certain client had called in for information. They found that 87% only called to one or two other agencies, one or two calls; the other 10% had made more than three calls.

Ms Purkis: Our fourth recommendation is that you support real consumer choice. Ensure that consumers are given choices. As providers, we welcome the chance to demonstrate that we can continue to compete in terms of quality, efficiency, cost-effectiveness and client satisfaction.

Identify the cost impact of the proposed system. Prove to Ontario's taxpayers that the proposed model's costs are at least no greater than the existing system. Identify the cost impact of the proposed system.

Protect current community professionals. Ensure that current community-based professionals are given complete and equal access to jobs in the proposed MSAs.

Establish pilot projects and evaluate the results. Establish several pilot projects based on a partnership model of service providers, using a single point of entry for clients in a given geographic area. Using standardized evaluation procedures, assess annually the results in terms of client satisfaction, cost-effectiveness, quality and other key indicators before proceeding with wholesale change.

In conclusion, if we can leave you with one last message, let that be: Make the legislation flexible and adaptable to individual and community needs and resources.

The VON is a 100-year-old national organization. It is a part of the heritage of our community. It symbolizes caring for life. It will be on this government's head if it destroys an institution that has been a leader in the development and delivery of innovative community-based health care and support systems for almost a century. Surely we can work together without destroying an organization that can never be replaced.

We thank you for your time, attention and the opportunity to present.


Mrs O'Neill: Thank you so much for coming together, for a thoughtful presentation and indeed, particularly on page 8, a very practical presentation.

You've asked with a great deal of focus some of the same questions as others -- you likely know that -- requesting a cost analysis, which we don't have on this bill, and I think you know very well the press conference that's being held down the hall at the moment; a request for research, and we haven't got any hard data; and I think you've been most strong in your request for a pilot project and actually offered yourself and ideas to go with that.

There seems to be a real intent here to overlook some of the statistics you've brought forward, such as the 10,000 volunteers, thousands and thousands of volunteers -- these are likely not the complete numbers -- and the role of charities in health care in this province, which goes back likely more than 125 years, and the complete ignoring of startup costs. I guess that's where I'd like to go.

It's very hard to know what to ask you, because you've got so much in this brief, but I'd like to go to page 7, if I may. Others have brought this to my mind and I don't think we've discussed it very much: the four-year horizon and the effect that's having on your planning in each of your branches; in fact, the effect this bill is having on your ability to plan, which indeed as we all know is a very high contributor to efficiency and effectiveness. Could you say a little bit more about how this bill has affected your planning, whether it be regarding facilities or equipment or indeed the startup of new programs? Then I have one other small, follow-up question, if I may.

Ms Burtch-Rudderham: I'd like to answer that question. In our region -- I'm in Peel region -- and in all of the regions, the long-term care task forces have been given the responsibility to set up individual MSAs specific to the community needs. I believe with this inflexible bill, Bill 173, we can't do that. We can't have local planning. Also, in all of the community consultations where I attended, and I was a facilitator at many, nowhere were they asking for this all-encompassing, monopoly MSA. They were only asking for easy access to program information and easy access to get into the health care system.

You've asked me how this changes our planning in an organization. I must tell you that it's really difficult to even plan for the future. None of us knows what we are doing. I often say it's like living in a Mixmaster and every once in a while a beater hits you and you don't know when it's going to happen next.

Mrs O'Neill: Good comparison.

Ms Burtch-Rudderham: So it really does involve all of our planning. If you think of transitional costs, I think they've said that a transitional cost for severance may be in the order of $25 million. Then we have leases on our buildings, leases on our fax machines, all our Bell telephone systems. Everything would have to be assumed. There are many costs in transition that I don't think have been thought about in Bill 173.

Ms Purkis: I would also like to add that I think there's an increased cost in resources as well, because as our human resources and certainly our financial resources are being directed so much to this planning and to wondering what we can plan and cannot plan, we are being deprived of the opportunity to carry on with our day-to-day business. We have to funnel so many of our human resources into being aware, being present at individual discussion tables -- in Metro alone, 18 separate tables. For Metro VON to be aware of what is going on, to make certain that our presence is there to send that very strong message that we are there to partner, takes away from doing the business we're supposed to be in business to do.

Mr Jackson: You're a big agency.

Ms Purkis: And we're a large agency, indeed.

Mrs O'Neill: And you're likely dealing with the social contract as another beater.

Ms Purkis: Oh, definitely.

Mrs O'Neill: Now, what about the bottom of page 7? You're the first ones, I think, who have suggested another structure, so to speak, because as we know, we have the DHCs very involved in the work that you seem to be indicating could be better done or at least done in companionship, and I'm a little confused about how you want to go further.

You just talked about the kinds of meetings you're already engaged in. Where do you see this advisory committee being different from what's happening at the present time? I do know that many people in this province, hundred and hundreds of them, are struggling with how they fit into Bill 173. Where do you see this advisory committee that you describe on the bottom of page 7?

Ms Burtch-Rudderham: If I can take you back to Peel region, because that's where I'm from, Red Cross, VON and Saint Elizabeth deliver 95% of the long-term care services now. If you think of an advisory committee, you could have two or three board members from each of the organizations to form an advisory committee, not a governance committee, and they could advise this partnership of agencies how to manage. Over and above the advisory committee would be the elected board that you want in your Bill 173 that would be elected officials in a committee. Does that answer your question?

Mrs O'Neill: So you don't have a direct relationship with the present DHC structure in mind. It would be more the advisory committee to the MSA boards.

Ms Burtch-Rudderham: We were considering that the DHC would be part of the advisory committee, so it would be representatives of the organizations and the DHC long-term care.

Ms Purkis: I guess the difference would also be governance as opposed to advisory. Governance is indeed setting policy, something that I think is a growing, learning experience that not everyone is familiar with. It's something that a lot of boards are struggling with at this point.

Mrs O'Neill: Of course, the role of the DHC is changing so much through this bill and through its present role in long-term care. That is, I think, what I'm trying to clarify in my own mind.

The Chair: Thank you very much. I have to look after the long-term care members of the committee, and we're going to have to take a break until we come back at 2 o'clock. We have a long afternoon to complete our hearings. We have had a number of submissions from your colleagues in different VONs, but we do want to thank you in particular for coming before us today with the presentation that you've made.

Ms Purkis: Thank you for your time, and I'd also like to acknowledge the large supporting cast that is sitting behind us today. We truly appreciate their presence here today.

The committee recessed from 1158 to 1410.

The Chair: Just before calling our first presenter of the afternoon, Bob Gardner, would you just note the document that you've circulated to the members?

Dr Bob Gardner: You have before you the third edition of the summary of evidence before the committee on Bill 173. This covers most of the briefs, almost all the briefs for the first three weeks. There are a couple that we're just finalizing and checking. Our plans would be to do that and to include these last two days in the final summary, which we'll get to you next week in good time for your clause-by-clause deliberations.

The Chair: Fine, thank you.


The Chair: I invite the representatives from the Ontario Chiropractic Association, if they would come forward. Welcome to the committee.

Dr Bob Haig: My name is Dr Bob Haig. I'm the director of government affairs for the Ontario Chiropractic Association. Mr David Chapman-Smith is the general counsel of the association. Mr Peter Waite is the executive director of the association.

You have before you a copy of our brief. I'm going to skip over the executive summary. By way of introduction, the OCA represents 1,500, or approximately 90%, of Ontario's 1,700 chiropractors. Chiropractic services are presently not commonly used in long-term care facilities, but this is likely to change. The OCA was not consulted during the development of Bill 173 and today is the association's first opportunity for meaningful comment.

In 1992, the Ministry of Health funded a study to examine the effectiveness and cost-effectiveness of chiropractic management of low back pain. This was performed by prominent health economists and their associates led by Professor Pran Manga from the University of Ottawa. The Manga report, delivered to the minister in August of 1993, contains the following finding and recommendations relative to long-term care.

Finding 8:

"In our view, the constellation of the evidence of (a) the effectiveness and cost-effectiveness of chiropractic management of low back pain, (b) the untested, questionable or harmful nature of many current medical therapies, (c) the economic efficiency of chiropractic care for low back pain compared with medical care, (d) the safety of chiropractic care, (e) the higher satisfaction levels expressed by patients of chiropractors together offer an overwhelming case in favour of much greater use of chiropractic services in the management of low back pain."

I have two of Manga's recommendations here.

Recommendation 1: "Current policy discourages the utilization of chiropractic services for the management of low back pain. There should be a shift in policy to encourage and to prefer chiropractic services for most patients with low back pain."

Recommendation 3 reads: "Chiropractic services should be fully integrated into the health care system. Because of the high incidence and cost of low back pain, hospitals, managed care groups (community health centres, comprehensive health organizations, and health service organizations) and long-term care facilities should employ chiropractors on a part-time and/or full-time basis. Additionally, such organizations should be encouraged to refer patients to chiropractors."

In October 1993, the Minister referred the Manga report to the Chiropractic Review Committee, a bipartite committee with representatives of the Ministry of Health and the OCA which was looking at a wide range of issues relating to access to and funding for chiropractic services. This committee, chaired by former Minister of Health Tom Wells is about to deliver its report to the minister.

There has at that committee been unanimous agreement on a number of recommendations, including recommendation 7.1, "That opportunities should be available for salaried positions for chiropractors in hospitals and long-term care facilities."

Following an extensive review process over 10 years, a new scheme of regulation of Ontario's health professions was enacted under the Regulated Health Professions Act of 1991. It is clearly important that new legislation that relates to health professional services should recognize the significant changes in delivery of health care services that have taken place over the last 25 years in Ontario and should allow appropriation, evolution and use of existing health care services as defined in the RHPA and its associated legislation.

Specifically with respect to the Long-Term Care Act, the draft provisions relating to health care services failed to recognize the changes that have taken place and are still taking place in Ontario's health care system. The provisions are inappropriate in that they define some services -- for example, physiotherapy and speech-pathology services -- as mandatory, yet exclude other services that have a potentially important role in long-term care facilities; for example, chiropody, chiropractic, massage therapy and optometry services. Also, secondly, the excluded services cannot be used by a multiservice agency, even on a discretionary or optional basis, without application to and approval from the Minister of Health.

In this submission, the OCA is not asking that chiropractic and other excluded services be included as mandatory services, though a good case could be made for that. However, the OCA does ask that multiservice agencies be entitled to use the services of any regulated health professional if, in their discretion, they feel that this is appropriate and in the best interests of patients. In other words, the act should be more enabling and less prescriptive.

A useful comparison can be drawn with the ongoing reform of the Public Hospitals Act. In the report of the Public Hospitals Act Review Steering Committee, entitled Into the 21st Century: Ontario Public Hospitals, is the following:

"The first premise is that the thrust of legislation should be enabling rather than prescriptive. The prescriptive components of the legislation should be directed to ensuring that the responsibilities of the hospital are defined and the hospital board is accountable for fulfilling them. Within this prescriptive framework, the legislation should provide the hospital with freedom and flexibility to organize its response to the needs of the communities it serves as effectively as it can."

Further: "Managing Access to Hospital Resources. Management's strategy for fulfilling the hospitals's mission and social contract should include a clinical human resource plan specifying the mix, number and types of regulated health professionals required in the staging of their appointments or employment. The Public Hospitals Act should guarantee the right of regulated health professionals to apply for appointment and require the hospital to respond to such applications."

With that general background, I'm going to turn this over to Mr Chapman-Smith to talk about the specifics of our recommendations.

Mr David Chapman-Smith: Bob's given you the principle that legislation passed in Ontario today really should be enabling and should be inclusive for all regulated health professions. The practical impact in this case, namely, a joint ministry committee, is about to recommend that chiropractic services should be in long-term care facilities; so it's a practical issue, not just a matter of principle. What I'm going to speak to you briefly now is about how that might be done.

If you look at appendix A, which the association has asked me to draft, first of all, I have the provisions in the current bill and, on the second page, our recommended way of fixing this. I'll just take you through this very quickly.

The way that the Long-Term Care Act is set up at the moment is that you have community services, as you well know, and underneath that you have a number of categories of services, one of which is professional services. Defined in section 2(7), in the definition section at the beginning of the act, are all the professional services. There you see them: nursing, occupational therapy, physiotherapy etc. and number 9 at the bottom, "Services prescribed as professional services." That would be something prescribed by regulation later.

Then, when you look at what services are provided within a multiservice agency, that's provided in section 12, which is divided into mandatory and optional services. The mandatory services, which you see in section 12(1), read, "Subject to sections..., a multiservice agency shall provide or ensure the provision of the following services," and then you have 1, 2, 3, 4, 5. Paragraph 4 is, "The professional services as referred to in paragraphs 1 to 8 of" section 2. The way things are set up, the mandatory services are just described as professional and then you go back to the definition section to see what those are.

Then at the top of the next page, still in the bill as it's drafted at the moment, subsection (2) provides for optional services and says that an MSA "may provide or arrange the provision of" these if the minister authorizes it to do so. Our submission is that it's inappropriate to have legislation today which suggests that some things are mandatory and the others are really not likely to be necessary and you've really got to get a ministerial discretion or fiat if you want to have them.


The suggested amendment, the way round this, is not changing, as Bob has said, in any way the overall intent of the legislation and it's not so intrusive that the chiropractic association is seeking to have the services of its members defined as mandatory; it's just permissive. First of all, in section 2(7), where professional services are described, instead of that section listing the various types of service, it merely indicates that professional services do include health care services, and then the other three paragraphs are ones that are already in section 2 -- social work services etc.

Then when you get to the section, namely, section 12, which describes the mandatory and optional services, paragraph 4 would list the professional services there. So you're bringing into section 12 the specific services, which are the same ones that were there before, but the scheme would be necessary to provide for what's in subsection (2). So the defined services are in subsection (1).

Turning to page A3, in subsection 12(2), optional services could be dealt with in this fashion:

"A multiservice agency may provide or arrange the provision of a service not mentioned in subsection (1)" -- ie, not mandatory -- "if:

"(1) With respect to professional services:

"(a) The service is a health care professional service from a member of a college as defined in the Regulated Health Professions Act;".

That's the one which opens it up to anything. The association is using that terminology because that's the terminology that has already found its way into other legislation; in particular, the association a few weeks ago made a brief to another committee of this Legislature that's looking at Bill 165 to amend the Workers' Compensation Act. That had various provisions referring to physicians only. A number of groups, including the chiropractors and the physiotherapists, and a number of consumer groups, said that was inappropriate, and that has now been changed in clause-by-clause to include this sort of rubric, exactly these words as an inclusive form.

Subsection (1)(b) is really just to capture the things that were already in the bill as already drafted:

"(b) The service is prescribed as a professional service, and the multiservice is authorized to provide or arrange the service, by the minister." All that is doing is capturing provisions that are there already. Then:

"(2) With respect to other services" -- these are community services that aren't professional" services authorized by the minister."

I won't have explained that entirely clearly, but the point is that there's a suggestion for the legislative draftsmen to look at. It's felt by the association that this is practical, that this achieves the principle we're seeking to see in the legislation, without changing the substance at all.

The Chair: Thank you. I would just note as well that you have attached to your brief the study dealing with low back pain for our information. We'll go to questions.

Mr Jackson: Thank you for a very concise, thoughtful and helpful brief. I wanted to, if we could, give you an opportunity to, by way of example, give us some of the areas of utilization for seniors with respect to chiropractic and how obtaining relief in one secures more independence at home, which I think is the underlying principle around mobility, comfort and ability for seniors and that it's more than simply a medical model because it extends itself to allow for that. Could you give us some examples of the importance of chiropractic in terms of long-term care, where we're trying not to institutionalize people? I use the chiropractic services but for different reasons. Could you help the committee with a few of those examples?

Dr Haig: You've almost answered the question yourself there.

Mr Jackson: Well, my mother uses it, but I'll be darned if I'm going to admit she needs long-term care at this point.

Dr Haig: In the population of patients who go to chiropractors, the only segment of the population that's overrepresented with respect to the general population is seniors, and there are many seniors who rely on chiropractors for exactly that, for mobility reasons. Now, chiropractors have not traditionally been involved in long-term care facilities, but any chiropractor in the province will have many patients who are able to function better on a daily basis -- can get around, can get up and down stairs, for example -- because of the treatment that they're receiving, and it is all related to pain and mobility. It's a very common thing.

Mr Jackson: Are there any concerns with respect to the fact that there is a fee, a utilization cost, for seniors to utilize your service? Have you thought through as an association the implications for utilization between if you're outside the legislation or within the legislation?

If you're part of the comprehensive team which looks at all aspects of an individual's needs to remain independent in the community, it would strike me as being somewhat wrong if we have one element of that support which is outside, which has a user fee, and forgive me for using that, but there is a contribution after a certain level of utilization for chiropractic in Ontario, that in fact that may compromise the continuum of care or independent living because at some point the senior citizen makes a conscious decision: "Well, I've used up the money that I can use for chiropractic. Therefore I'm going to not use chiropractic and therefore I'm going to put more pressure on other elements of long-term care because I am less mobile."

In my view, that's the biggest fear of keeping chiropractic outside of the circle of collective services that come together to help a senior citizen. This is one component part they just say, "Well, I'm stopped using them because I can't afford them any longer." That's the wrong thing to happen in long-term care reform.

Mr Chapman-Smith: If I could answer that, there are two problems: There's the user fee, but there's also the simple fact that chiropractic services are traditionally fee for service. For example, the Long-Term Care Act doesn't cover medical services because those are on a fee for service, and it hasn't traditionally covered things like optometry and chiropractic for the same reason. So there are the twin problems, the overbill and the fee for service.

But what's quite clear in the current reform in the system is that a lot of different providers, and it's anticipated a number of chiropractors, in the future will be moving on to salaried positions in different health care settings, and I think this gets to the sting of your question. What that means is that this opens the way for a chiropractor to be salaried in this sort of setting and be available to seniors with these needs at no cost.

Mr Jackson: I see that as one issue, but I also see this other issue of, as user fees become more prevalent throughout the system, whether it's for home testing, lab testing, for which now there's a user fee that's cropping in, all the way around, where seniors elect to say, "Look, I'll do without that service," I see that doing without chiropractic, for some of my seniors, means they're going to need more services from the long-term care system. Because they've impaired mobility, they now need someone to help them do their grocery shopping. Because they can't have proper leg movement, they can't get on a bus. Therefore, if they can fall under the line to get the definition that they lack the mobility, then they need more expensive types of transportation support.

I see all these as occurring because we failed to bring chiropractic into the bill in a way in which MSAs are structured to look at a holistic approach at how all the senior citizens' needs are covered.


That's the point that's frightening me, that we're not including you in this regard, because the capitation approaches and all those other things are different issues, which I don't know if we want to get into right at the moment. But it's that kind of concern I have for seniors. I don't see anybody advocating that we take that complete approach, and if we're going to do that, why are you outside of that? It's an open-ended question.

The Chair: It can have multiple answers.

Mr Jackson: One would do.

Mr Chapman-Smith: Well, I'm not quite sure what to say to that. I mean, I hear your comment. There are so many issues that arise out that.

What I've been thinking of as you're speaking is the whole wider funding issue for chiropractic services in the province, which has been subject to a lot of debate at the moment, but its practical impact, felt particularly by seniors, is that whereas a few years ago the overbill was about $1, although chiropractic fees have remained well within the inflation index, over the period the cost is now like about $17 or $18 a treatment out of the pocket, and that particularly hits elderly people. So there are wider funding issues in many areas which are making it difficult for seniors.

Mr Jackson: Well, I think I've made my point. I hope we're not penny wise and pound foolish with this, for the simple reason that a lot of our seniors are utilizing chiropractic so they can live independently of institutions. I'm surprised that this late in the hearing process -- and I lament and apologize that chiropractic was not consulted more directly up front in this process, and to whatever government ministry wants to respond as to why that happened, I can let them explain that, but I'm sorry it did not occur, because I see you as part of the wellness continuum.

The Chair: Thank you very much. I have to note that we've been trying to get as many presenters in as possible and there are more questions but we'll have to move on.


The Chair: I call on the representatives from the Association of Community Information Centres in Ontario. Welcome to the committee.

Ms Carol Jones-Simmons: I'll introduce us. My name is Carol Jones-Simmons. I am the membership development coordinator for the Association of Community Information Centres in Ontario, and this is Monica Stewart, our association vice-president and the executive director of the Kingston District Community Information Centre.

We'll spend a little bit of time introducing who we are and what we do, because we feel we are not a very well understood service and it relates to our presentation, and then we'll go into the four major concerns that we have with Bill 173. You have our position paper on equitable access, and we've also included a directory on community information centres in Ontario for the use of committee members for your information.

The Association of Community Information Centres is an umbrella organization representing 70 community information centres in Ontario. Our vision is that all Ontarians should have equitable access to human services information, and by human services information we mean social services and health services. As an association we provide leadership to our member centres in the area of standards of service delivery, professional development, marketing initiatives and information technology.

One of our major accomplishments in the last several years, through the assistance of a Trillium Foundation grant, was to develop an automated network of community information centres that collect similar data and share data across Ontario. We believe in partnerships and working with governments and other service providers and consumers to improve access to services, and we have been working diligently in the area of long-term care and community support services.

I'll turn now to Monica Stewart to give you a little background on community information centres.

Ms Monica Stewart: I'm the executive director of the community information centre in the Kingston district, and as such I guess I'm well placed to tell you a little bit about what community information centres mean to their communities, for those of you who might not be familiar with the CIC in your own community.

What we do best is match people with services, and we have over 30 years of experiences in linking people to a complex human service system that is changing greatly over time. We help not only the consumers but also the service providers to navigate this complex system.

In 1993, CICs across the province of Ontario handled over 860,000 inquiries from people who don't know where to turn. Community information centres have adapted their services to multilingual communities, the elderly, the physically disabled and, through 24-hour access here in Metro Toronto, to the particular needs of a large urban community.

CICs are also the only organizations in the community whose primary mandate is information and referral. They know the complexities of the system and they have developed expertise in a number of areas. Most of them provide a publications program, referred to as community directories; they provide training to their own staff and other service providers on how to navigate the system; they provide data management for their own large community information databases; and they also report on trends and gaps to other community agencies.

Each community information centre collects, maintains and updates a comprehensive database of non-profit community services and government service information, and the breadth and the depth of these CIC databases are unparalleled in their catchment areas. CICs are partners with the United Way, local and regional municipalities, government ministries in the provincial government such as Culture, Tourism and Recreation, Community and Social Services, Education and Training, Health and Citizenship, and within the federal government such agencies as Human Resources Development Canada. Also, in addition to this, community information centres have the services of about 1,200 to 1,400 volunteers who help out on a regular basis with information and referral services that we provide.

I'd like to tell you just very briefly and point out to you that in our brief we have given you a story of the type of information we provide to people who contact us, and you can look at this at your leisure, because we often find that it's difficult to explain to people the breadth of the type of service we provide within the centres. That's on page 3 of the brief.

Ms Jones-Simmons: With respect to Bill 173, there are many things we support, actually, in terms of the government's initiative in this area. We support the fact that there are alternative models for an MSA coming out of the local planning process, and we support that consumer needs ought to be a primary criterion for determining services. We believe that consumers should have choice, they should have quality standards in services, they should have equitable access and they should have an efficiently managed system. We feel there are some concerns, though -- we have four of them -- that may jeopardize having those two major points of our support not being implemented.

With respect to section 1, the purposes of the act, we feel that consumer needs ought to be the top priority for determining access to services, not rules and eligibility criteria. We feel there may be a lot of people who will fall through the gaps who will not be connected to a multiservice agency without some sort of assistance through a community information and referral type of service. We have made some recommendations on changing the wording of three sections from section 1 to emphasize the primacy of consumer needs as the major criterion in determining access.

A second part of the purpose refers to another belief, that we feel there are many strengths in the current system that could be used to build a foundation for an improved system, that it is not necessary to reinvent services. Necessarily, they may need to be improved or integrated, but they do not need to be reinvented at great cost. So we have added some wording to clause 1(f) to emphasize that existing community services, where there are strengths in them, ought to be utilized in developing a new system.

I'll turn to Monica to give you some background on the way we feel information referral hasn't been adequately dealt with in sections 14 and 20.


Ms Stewart: I'd like to address our third concern, which is that there is not adequate coverage at this point in the act of information and referral services. We understand that information referral is to be a major component of the multiservice agency, and we feel that that needs to be expressed in the act more clearly. Therefore, we are recommending the following amendments.

In subsection 14(2), to add to the existing section a sentence, "and other service providers if the consumer's needs can be met appropriately by them." That's on page 6 of our brief. What we mean by this is that in an instance where you have a person who is not referred within the multiservice agency system or to a service that is linked to the MSA, you would still give that person some sort of information that would assist them if it's available within the community.

We also feel that there should be a definition of the word "referral" added in this particular section, and we would like to see referral defined as something that includes the liaison with the person until a connection to an existing service is made.

We also would like to see something in the legislation that provides for those consumers who contact the MSA and are not within the purview of the MSA in terms of eligibility, and we recommend that section 20 be amended as follows: It says in there, "When a person applies to an approved agency for any of the community services that the agency provides or arranges, the agency shall," and we recommend that we add, "(d) for each person who is deemed not to be eligible, ensure that the person is linked with a community information and referral service." Again, that hearkens back to the whole intent of the act, that you don't want people falling between the gaps, as they are now, and this is something that is missing here. What happens to the person who actually did not fall within the mandate of the multiservice agency?

In addition to that, we would like to see an amendment to subsection 56(1), which deals with the regulations, by adding something that would create awareness of the existing community information services that are represented by this association and a recognition that information centres or information services are now in existence that hold a vital part that will assist the MSA to make the service that much better for the end consumer and make the access to long-term care services easier for everyone.

We are recommending that the following be added:

"43 requiring multiservice agencies to incorporate existing community information and referral services within an overall plan of information and referral services for long-term care and support services in the local community."

Ms Jones-Simmons: In conclusion, I want to stress that the association works in partnerships with other service providers and with consumers and with government, we hope, in trying to improve the long-term care system, that we commend government for supporting community services and for encouraging the local planning process, but we do feel that changes are necessary in order to ensure the best possible system is developed for Ontario residents.

Ms Carter: Thank you for your presentation. I think we'd all agree that information is absolutely crucial to this whole enterprise, and I know we have had presenters who have emphasized that side of it, that we're going to have to make use of technological possibilities to have everything running smoothly and give the best possible service.

But, to me, this is the point: I feel that we're not abolishing what's there and starting again; we're building on what's there and trying to bring it closer together, and of course one of the main reasons why we're doing that in this bill is to gain efficiency and better communications. Obviously, the service coordination aspect is one of the main things about the MSAs; you know, that people will be able to make this one telephone call and get a response from somebody who has available to them all the relevant information. So I kind of feel that that is built in as a very important and basic part of what we're doing in this bill.

I'm sure you will have in your databases a lot of information that would be useful or whatever, so whether you would be integrated or you would hand over that information or what, I'm not quite sure. But the idea that people are going to be left dangling I hope and believe is not going to be the case. Somebody might phone in with a very simple request like, "I need Meals on Wheels," and hopefully the relevant arm of the agency can be contacted immediately and that person would get the Meals on Wheels, I hope, the next day.

But very often requirements are going to be complex. As I say, a main part of this system is that there will then be assessment of the person to find out exactly what they need, with the person's wishes taken into account as to what services they would prefer to receive. Obviously basic to that is going to be to have information of everything that could possibly be relevant, and that would include accessing services in a different geographical area. Maybe the person has an ethnic background and wants to go to a service that reflects that or whatever. So I feel that's there and I don't know what I can do here: just reassure you or ask for your comments on what I've said or whatever.

Ms Stewart: Perhaps I could just respond to that briefly. I believe that you think it's there. It's very obvious from your comments. We also believe it's there, but we don't believe it's there uniformly across the province. There are proposals going in right now from Kingston, Windsor, from London I believe, from Hamilton and Ottawa that address these kinds of integration issues, making sure that everybody works together. What we really feel strongly about is that this be something that is put into the legislation so that we make absolutely sure that it's happening everywhere, and not just in those communities where people like yourselves are very aware of these types of services.

Ms Carter: I guess again that's part of the object of the act, to make sure that services which are maybe functioning very well in some areas are available to everybody across the province. I think we're all well aware that at the moment that's not the case, that some areas are well served, some have one service and maybe somewhere else has a different service but not that one, and so on. We want everything to be available. But certainly the information base is going to be absolutely crucial to every multiservice agency, not just for their own area but for the whole provincial picture as to what's available to their clients.

Ms Jones-Simmons: I think it's just that we wanted to be sure there was some recognition that there are lots of things we can offer to this process. I mean, in not all cases across the province has it been easy for us to make that case. I think it's been happening in some communities faster than others, but we feel in some cases it hasn't been happening very easily at all.

Ms Carter: I'm certainly well aware of my own local branch of your organization. Marilyn Huels is in touch with me and I've been there and found out what they do, which is obviously very valuable.

The Chair: Thank you very much for coming before the committee and providing us with information about the centres, and also the profiles, which is always helpful.



The Chair: I call on our next presenter, Pamela Gray. Welcome to the committee. We have a copy of your presentation, so please go ahead.

Ms Pamela Gray: I want to start out at the outset by saying that I come today as a private citizen and I come today as a nurse working in the long-term care area but I do not represent a particular agency with my comments. I am coming before you today to inform you of what has happened to me in the past, in the hope that you may understand my genuine fears for my future.

Over two years ago, I lost my position with a volunteer agency as a nurse case manager because of a severe shortage of voluntary donations to this agency. The downturn in givings was triggered by the serious decline in the economy. It took me 10 months to find my present position with a community provider of health care service.

I see the changes to the present health care system legislation as a significant threat to the employment of thousands of nurses, home health workers, occupational and speech therapists and physiotherapists. Nurses within the agencies who act as supervisors of care and middle managers will also lose their jobs.

There are no guarantees that the new MSAs will be able to employ all these skilled workers. Hospitals will not be an alternative source of employment for this group, as funding to institutions is now severely restricted. This significant disruption to long-term health care delivery is really an assault against the skilled women of this province who carry the daily burden of providing quality health care to seniors and the disabled in Ontario.

Will this government be willing to provide support and retraining to any class of worker displaced by this legislation, including those at a higher skill level? The process to do this must be in place before the legislation is passed.

The agency for which I work will not have enough work to make it financially feasible to continue its operation. Though our government homemaking hours constitute 43% of our business, our private business cannot make up for that loss if we lose the ability to serve our clients. Our clients have very vocally made it known to us that they desire consistency in the provision of their home support hours. They have demanded the same agency and the same worker again and again. This new legislation removes their ability to have any choice in the provision of their own personal care. Right now, if a consumer or her family does not like the care provided by one agency, they can call another. No such choice will be available to clients after this bill is passed.

In Durham region, I have been attending meetings of the long-term care committee of the district health council. At our last meeting, on September 20, 1994, we drew a number of conclusions about our present system. Of special significance was the determination that our present system lacks the ability to share information between agencies about the same client. Presently, each agency must question the client separately about his or her health status and significant problems. An integrated assessment form would relieve pressure on the client to provide the same information over and over again. This better information system could go a long way to diminishing the duplication that now may exist in provision of long-term care. This is but one measure that could be taken to improve our long-term health care system without resorting to drastic legislative measures.

I truly believe the components for excellent health care for seniors and the disabled already exist. Let's find a way together to inform the public of the services already available before drastically changing the system, and please do not make the changes on the backs of skilled and educated women like myself who will have no place to turn for another job.

Finally, I recommend that section 13 of Bill 173 be removed.

Mr Dalton McGuinty (Ottawa South): Thank you, Ms Gray, for your presentation. We've heard from a variety of organizations here on behalf of their respective memberships, and it's good to hear from individuals from time to time. That's not to belittle the other presentations or presenters, but it's just good to hear from individuals who will be directly affected by the legislation we're considering.

You raise some very good questions about your prospects for future employment should Bill 173 become law. After all, as my kids tell me, this is the 1990s, and in an employment context the mid-1990s in Ontario are difficult times. But I believe they are particularly difficult for nurses. There aren't a lot of jobs there.

I am going to allow the parliamentary assistant the opportunity to respond to one of the questions you've raised. I'm going to rephrase it, and if I haven't phrased it correctly, then you can address that. To the parliamentary assistant, what solace can you provide Ms Gray with respect to her future prospects for employment should she lose her job? What compensation will there be, what retraining will there be, things of that nature?

Mr Wessenger: First of all, I think I should make it clear that it's certainly the opinion that those people who are delivering services directly are not likely to lose their employment. I think the concern expressed here was with someone at the middle management level, and that is obviously a legitimate concern. What I could tell Ms Gray is that the other day we had HSTAP before us, who indicated that they had been given responsibility for dealing with the situation with respect to any job losses in the community sector, as well as continuing their responsibilities for job losses in the health sector in general. So, yes, HSTAP will have this responsibility.

The other question that was asked was, what about the client/care giver relationship? Certainly it's the opinion that in the move to the MSA, one of the principles should be that there should not be a disruption of the relationship between the person giving the care and the client. It's certainly the intention to try to integrate people in the community, whoever their employer is, into employment with the MSA.

Mrs O'Neill: Mr Chairman, could I please clarify something? I have a lot of difficulty with what Mr Wessenger has just said about HSTAP, because they came here and presented to us and asked to be involved in the process. They said they were very willing to be involved but had not to this point been consulted. Are you suggesting now that they are really involved in this? Because that was not the impression they gave us yesterday morning.

Mr Wessenger: If I might just clarify, I think the point HSTAP made is that although they had the responsibility for dealing with any job losses in this area, they wanted to be involved in developing guidelines for a human resources plan with respect to dealing with the MSA situation, and they were asking to be involved in the development of the guidelines that are going to be given to individual MSAs, which the ministry is presently working on.

Mr McGuinty: Ms Gray, I appreciated your point as well about how what we should be doing is capitalizing on the existing strengths that are found within the long-term care system in Ontario today. It's my view that government ought to be acting complementary to or supplementing what is found out in the community, and not attempting to supplant it or replace it. You join a long line of critics who have rendered severe judgements on Bill 173. We have heard from folks like the Red Cross, Victorian Order of Nurses, Saint Elizabeth Visiting Nurses' Association of Ontario. Any moment now I'm expecting Mother Teresa to walk in that door and lodge complaints about Bill 173.

It's not too late yet. Let's hope the government is still considering this. Thanks for coming up.

Ms Gray: May I make one further comment? It is my understanding from what Mr Wessenger has just said that HSTAP is involved with the redeployment of laid-off hospital workers, and it was not my understanding that that would extend to community people as well. Is that now going to be extended to the community system?

Mr Wessenger: I understand it will be extended to the community system. That's certainly what HSTAP said to us when they presented the other day. I might, just for clarification, indicate that they have been involved in the development of guidelines. I think what they were asking for is to ensure they continue to be involved, and perhaps in setting up the system.



The Chair: I call on the representatives from the Canadian Union of Public Employees, Ontario division. Welcome to the committee.

Mr Sid Ryan: My name is Sid Ryan. I am the president of CUPE Ontario. Donna Powell is a member of our health care workers' committee. Margaret Evans is a CUPE researcher.

Many CUPE workers in Ontario are front-line health and social services workers in hospitals, long-term care facilities, municipalities, public health units and community social service agencies. On behalf of CUPE members as consumers, providers and taxpayers, the Ontario division welcomes this opportunity to make a presentation to the social development committee on Bill 173.

We are very pleased that the government is putting forward the legislative framework which will provide for one-stop access to long-term care services. Streamlining community health services under the umbrella of multiservice agencies will reduce waste and enhance access. Our support, however, is not without reservation. While we support the concept of adequately funded multiservice agencies directly providing core services, there are serious weaknesses in the bill which need to be addressed. I only have a short time today to give you an abbreviated version of some of our concerns. For a full explanation of our position, I urge you to read our brief.

On the question of governance, we cannot accept that workers do not have a legitimate right nor place on the boards of directors of publicly funded health institutions. Their knowledge, experience and judgements are invaluable to other board members who may not be so closely involved with the services being provided and with the persons receiving those services. Two of our recommendations on governance are, in abbreviated form once again:

(1) That section 2 of the bill should be amended to provide for a mix of appointed and elected representatives based on the Quebec model for CLSCs and other health and social service facilities.

(2) That labour should be able to nominate the labour names to district health councils through a joint OFL-ONA nominating committee.

I must reiterate that for our complete recommendations, please refer to our brief.

Direct provision of services: We are pleased that the government listened to critics of its first long-term care strategy paper. The government changed its direction and proposed instead a model where brokering between consumers and providers of services would be the exception, not the rule. We were therefore very disappointed to see that section 13 of the bill weakens this commitment. It allows up to 20% of services to be contracted out. Allowing agency resources to be contracted undermines one of the five stated objectives of Bill 173, namely, that of achieving consistency in the system and improving accountability, and threatens the future job security of multiservice agency employees.

One of our three recommendations in this area is that Bill 173 should enshrine the preference for non-profit agencies and stipulate that where services are available from non-profit agencies, MSAs should provide such agencies with the opportunity to provide such services prior to purchasing them from a for-profit agency.

Consumers' rights: The inclusion of section 3, a bill of rights, in Bill 173 is laudable and we agree with the principles and rights which are enshrined in that section.

Are people to have the right to the community services they need in Ontario, or are they to have the right to go on a waiting list? Will the appeal board dismiss an appeal of denial of services if an agency can demonstrate that a person in need of a service has been placed on a waiting list?

One of our recommendations in this area is that Bill 173 should enshrine the right of persons to any professional personal support, homemaking and other community support services which are necessary to enable them to live independently in their own home and in other community settings in dignity and with security.

Designation of multiservice agencies: It seems the Ministry of Health intends that municipalities and boards of health can only be multiservice agencies of last resort. Municipalities and boards of health have years of experience in administering, delivering and being accountable for a number of services which will, in the future, be delivered by multiservice agencies. We do not believe it is in anyone's interest to lose such valuable expertise and experience.

We would recommend, among others, to delete from Bill 173 subsection 11(3), which makes municipalities and boards of health multiservice agencies of last resort.

Quality management: CUPE has had extensive experience with quality management programs like total quality management, continuous quality improvement, patient-focused care and system re-engineering. These programs are being sold to employers as ways to assist them in increasing productivity, at the same time as cutting labour costs, without sacrificing acceptability in terms of quality of the service being provided. The idea is to constantly find cheaper and quicker ways of providing the service. At the end of the day, workers are being asked to do more in less time, creating workload stress and health and safety and burnout problems.

We would recommend that subsection 52(1) of the bill, which exempts records dealing with quality management activities or quality improvement activities from the inspection provisions of the act, be amended to delete this exemption.

Volunteers: CUPE recognizes the valuable contribution volunteers have had to make our health care system work. However, we are very alarmed at what apparently seems to be a definitive shift in government policy towards the increased use of volunteers in the health care field. We do not agree that volunteers should be performing the work of bargaining unit members.

One of our recommendations in this area is that subsection 56(11) of the bill should be amended to clarify that any plan for the use of volunteers should be restricted to activities not usually performed by members of bargaining units of unions which represent health and social service workers.

User fees: CUPE does not support user fees. We would like to see a lot more discussion on whether user fees are appropriate. The government should release a discussion paper on the subject and conduct further consultations.

We would recommend that the standing committee on social development urge the government to make a commitment that before any regulations are made which would permit the charging of user fees for homemaking or community services, a discussion paper on the subject will be released and further public consultations will be conducted.

Fair wages and employment security: CUPE and other unions representing health care workers have repeatedly called upon the government to initiate a process for a province-wide employment security agreement for health care workers to help deal with health care restructuring. A comprehensive employment security agreement must involve an effective and enforceable redeployment system to be administered by the health sector training and adjustment program, HSTAP.

One of our recommendations: that the standing committee on social development urge the government to initiate a process for a province-wide employment security agreement.

In conclusion, the Ontario division of CUPE supports the logic of consolidating existing services for long-term care and the creation of multiservice agencies which directly provide in-home and other community support services.

While giving our support to the overall objectives of the bill, we've explained some of our reservations on a number of key aspects. We hope the standing committee on social development will take our concerns into consideration during its deliberations. Thank you for giving us this opportunity to present our brief today.


The Chair: Thank you very much. I will just underline as well that there are other recommendations which you weren't able to underline, but those are all summarized at the end of your brief and we'll certainly look at those.

Mr Jackson: Thank you, Mr Ryan, for your presentation. There is a lot more content in your brief and you had to run through it as you forewarned us, and I had a little bit of difficulty keeping up, but you have a very fulsome report here which some of us will have to have a more extended look at.

The one that comes up on the page that I was on at the time was the issue of volunteers. Could you help me? By way of example, you used the notion in your recommendation 14 that "volunteers should be restricted to activities not usually performed by members of bargaining units of unions which represent health and social service workers." Have you got a couple of examples you could share with us? This whole sector is a patchwork between certified, uncertified and volunteer workers all doing different things but sometimes similar things. Have you got any examples that you could share with us?

Mr Ryan: Certainly. One area where we would not want volunteers getting into is obviously the hands-on personal care, which clearly is within the jurisdiction and the mandate, I guess, of the bargaining unit members who work in our long-term care facilities and other agencies. Where we would see a role for volunteers would be in the recreational elements of the long-term care program.

It's no secret that patients in long-term care facilities, because of cutbacks in government funding from all levels of government -- not just from provincial governments; we have it at the federal as well as municipal levels -- we're finding that the patients are being left sometimes in the corridors on their own with nobody to speak to, no compassion whatsoever. Compassion has gone out of our long-term care facilities. We used to, as front-line providers, be able to spend some time and talk with the patients and help them, I guess, overcome the feeling of loneliness. That's missing from the health care field these days. We see a role there for volunteers. We don't see a role coming in, for example, to help bathe or to feed or to do the hands-on care that we would provide in those facilities.

Mr Jackson: That's the question I was getting at, was examples where if you were to go to, say, Kingston, this service is being provided by an organized worker, but if you go to Woodstock, it's being provided by a volunteer. Can you share with the committee any specific examples? You've answered my question, but it was in general terms and -- just help direct us to examples of that. Are there cases of people being paid to do Meals on Wheels when it is extensively being done by volunteers, and do we anticipate Meals on Wheels continuing strictly on a volunteer basis, or --

Mr Ryan: I brought Donna Powell with me and Donna actually is director of volunteers in her home, so perhaps she can answer that question better than I could.

Ms Donna Powell: Meals on Wheels is done in our particular area by Red Cross. It is usually a volunteer, but they don't have direct contact with the residents. That's more into the community. In the homes, volunteers in our particular institution do one-on-one visiting. They help staff in recreational services doing programming. For volunteers to do direct care -- you're talking feeding and bathing and things like that -- there is an element there that -- for instance, in feeding, people who have to be fed are potential chokers. I myself have been in the nursing aspect of it and it's quite an ordeal if somebody does start to choke.

Mr Jackson: I'm not challenging the need for professional services for those scenarios; I was just trying to determine --

Ms Powell: I know what you're saying, but volunteers shouldn't really be put in that position.

Mr Jackson: Okay.

Ms Powell: It's a very frightening experience. I don't think most volunteers would like to be in that position and I don't think it's up to us to put them in that position.

Mr Jackson: Could I ask some questions, then, around the issue of the displacement of workers? We've heard a lot from groups around that issue and to the extent that you've had discussions with the government around the re-employment prospects and/or the severance packages for -- within Red Cross or within VON or within Saint Elizabeth there are some that are bargaining units and some that are non-bargaining units.

Have you had any discussions in detail you can share with this committee about options in the regs or in government follow-up to this legislation regarding job security, but then, more importantly, rehiring provisions? Is there a hierarchy being recommended? Could you help enlighten us with that? Because your report talks about that they should be protected, but we're proceeding with this and we should have something in legislation and/or there should be some dialogue with the government going on now. You do represent some of these workers, some of whom may be displaced or will be displaced.

Mr Ryan: Sure. We're dealing with that very question. First off, let me say there are a lot of misconceptions about what the unions mean by "employment security." Employment security is not job security. We would like job security; we'd like to have a job guarantee for life, but we know that's not the reality in the 1990s, so the next best thing we can get is an employment security agreement, which basically states that if you're laid off in a nursing home -- and I'll just take an example of a nursing home at the west end of the city -- and they're hiring in a nursing home at the east end of the city, it makes an awful lot of sense for us to retain the skills within the system.

Instead of going to the streets and hiring a person off the street and having to put money into training those individuals to come up to be able to provide the care in the home at the east end, we're saying, let's have a registry, preferably inside of the HSTAP program. Laid-off workers would be registered. When a vacancy occurs somewhere in the system, we would then go to that list of qualified workers, take that worker out and place them in the new vacancy, thereby utilizing the skills and keeping the skills within the health care field. That's what employment security means. A lot of people misunderstand that to say we want guaranteed job security. We don't.

Some complications: What happens if a person who is laid off in a non-union nursing home, for example, applies for the job? Where do they fit into the system? Those problems have yet to be worked out, but we're working on them. In terms of discussions with the government, we did have a discussion a long time ago, several months back, in the health care field, primarily around hospitals. It hasn't gotten to a point where we're satisfied with it, so we've tried to open up discussions with the government on a broader scale dealing with employment security across all sectors -- in other words, the same things for school boards, municipalities -- and they're in the very early stages.

Mr Jackson: But in this legislation in particular, you recommend that the 20% purchase-of-service agreement threshold should be reduced to 10%. Without getting into the issue of hospice and commercial versus not-for-profit, we don't agree on that point so there's no sense us debating it and you're entitled to your strong views in that.

But I do, however, want to get an understanding from you if you're aware that by asking for the threshold to drop from 20% down to 10% it further compounds worker displacement, because that will mean more agencies will have less access to participate and therefore whole organizations will be told, "Look, they won't buy our service, so therefore we have to lay you off, but they're hiring," because they're now an MSA, a whole new entity which is going to be hiring or providing 80% of it as direct service and only 20% would be -- so a unionized worker at Red Cross is going to get laid off because they're an insufficient amount of the 20% of an MSA's capacity to purchase services.

I don't mean to suggest you're running against each other on this. You may have some other reasons for why you want the 20% threshold dropped to 10%, but it further compounds worker displacement which, whether a worker is unionized or not, they're still a worker in this province and they shouldn't necessarily be displaced in these large numbers, as we're expecting may occur.

So could you comment on directly the displacement of those kinds of workers -- and not the nursing home example, because they're not really affected by this legislation.

Mr Ryan: First off, I disagree with the premise that we're talking about the displacement of workers. If the MSAs are simply an opportunity to bring underneath one umbrella or one-stop shopping, if you will, all of the services that currently are provided within the community, I cannot see how we're going to see job dislocation.

What I do see is a difference between, is it delivered in the not-for-profit sector versus the for-profit sector. I believe the same number of jobs should still exist; I believe those people who are working currently in the for-profit sector and the agencies will have the opportunity to move across into the MSAs as those MSAs are up and running. I believe that the figure of 20% is an arbitrary figure. I don't know where it came from; it's not, as far as we can see at least, based on what's currently happening in the system. Is 20% roughly the figure of for-profit services currently purchased today?

Mr Jackson: Mr Ryan, I'm sorry, there may be a misunderstanding here. The 20% figure is for the purchase of all services, regardless of whether they're not-for-profit or for-profit. In fact, an MSA could say, "We're going to buy zero for-profit services, but only 20% of the total number of services we'll buy will be from not-for-profit agencies." In fact, there's no union protection in this legislation, so they could even go so far as to say, "We're going to hire 20% from outside non-profit agencies who aren't unionized." The MSA has that much power, but the 20% figure -- they moved from 10% being just for-profit. They moved that threshold up to 20%, but included everybody.


Perhaps that understanding wasn't clear in my question, but that's why moving it back to the 10% actually displaces more workers, because these people can't continue to work for the Red Cross because the Red Cross can't sell that service to people. These workers have to move from the Red Cross and get hired by the MSA. I was always taught that was worker displacement, and so we have to consider their years of service, if they're on an experience grid, if they can transfer some of their benefits package and privileges. All those things are implicit in worker displacement, as you know better than I do.

But I'm just trying to determine in this legislation, there's no protection anywhere in all of this, but moving the 20% down to 10% displaces even more workers than will already be done by this legislation. They will be under this umbrella, but they'll be actually employed directly by this MSA entity. Maybe I wasn't clear enough, but those are the areas of concern I wanted to explore with you.

Mr Ryan: Perhaps Margaret could take a shot at that.

Ms Margaret Evans: I'll give it a crack. If I understand your question, you're asking whether lowering the threshold from 20% to 10% for purchase of service ends up creating more disruption for those employees who are currently providing services in a number of agencies in the community. I think the whole premise of Bill 173 is based on the idea that we're going to start shifting services from institutions to the community. The whole premise of the new direction for long-term care with multiservice agencies was the idea that instead of having a multiplicity of agencies providing home care services in the community, you would consolidate these services under one agency and provide one-stop shopping for persons in need of long-term care.

So, obviously it's going to result in situations where the employment status of people will change, whereas before members might be employed either by a hospital or a long-term care institution or a public health unit or a municipality or a voluntary agency. Under the provisions of this bill, at least 80% of those persons would be directly employed by the multiservice agency, and what we're saying is that we think that threshold could be 10%.

I think perhaps the key question that you were getting at, and it's an area where I think there's some misunderstanding of what the position of the labour movement is, is that we're not saying that the people in the voluntary sector or people who are not unionized shouldn't go with the work. We're in support of people who currently perform those services in the community moving with their jobs to the new multiservice agencies.

Mr Jackson: Where is that in the legislation to protect that, was my question.

Ms Evans: What we're saying is, there is nothing in the legislation and we think there should be and our recommendations 17 and 18 deal with that.

The Chair: I regret that our time has run out, but we do want to thank you all for coming before the committee today and for your presentation. I wonder if I could also note, I understand, Miss Evans, that you at one time worked here as a parliamentary intern --

Ms Evans: That's correct.

The Chair: -- and say to members, because we're right in the process now of looking at interns, so people can see that there is life after the parliamentary internship. Welcome back.

Mr Jim Wilson: Does she get a chance to comment on it?

The Chair: Thank you again.


The Chair: I call on the representatives from the Service Employees International Union. Welcome to the committee.

Ms Judi Christou: My name is Judi Christou. I'm assistant to the president of Local 204. With me are Marcelle Goldenberg, who is the director of research, and Ted Johnston, who is a researcher for the Service Employees International Union. We welcome the opportunity to present our views to the standing committee on social development concerning Bill 173, the Long-Term Care Act.

SEIU represents approximately 45,000 workers across Ontario; 11,000 of these workers work in a long-term care sector and an additional 27,400 workers are employed in hospitals. An estimated 85% of SEIU members are women and a significant number are from minority groups.

This submission has four salient points:

(1) To express conditional support for the intent and direction of Bill 173 to improve the delivery of community-based health care and support services.

(2) To express concern about the lack of definition, detail and criteria in the act; too much is left to undeveloped regulations. Consumers lack choices and can't tell what they will be getting.

(3) To express serious reservations about how the shift to community-based services would impact on SEIU members, especially in light of the lack of any labour adjustment strategy for the long-term care sector.

(4) To express concern that, despite some effort, there are inadequate opportunities for participation by labour, especially at the local level. This lack of input is reflected in the fact that the government's main strategy is to achieve cheaper health care by exploiting workers, volunteers and families.

SEIU is a stakeholder in the long-term care system. The long-term care partnership papers recognized labour as a stakeholder and promised labour full involvement. SEIU has participated in consultation meetings, focus groups, resource groups, and we previously made a submission to the government regarding Bill 101.

However, despite its extensive participation, SEIU is disappointed that it cannot assume that its message has been heard. It must continue to fight for involvement. Indeed, to read Bill 173, it would appear labour was not a significant part of the process. In making a submission to this committee, SEIU feels it must repeat the reasons why labour has an interest in this reform and a contribution to make.

Naturally, we acknowledge SEIU's primary objective is to protect the interests of its members. At the same time, it recognizes the labour movement has always played a major role in the development and maintenance of an efficient, economical and caring health system. The best interests of SEIU members, more often than not, coincide with those of consumers.

SEIU represents 45,000 front-line health care workers. From another perspective, SEIU represents 45,000 consumers who have intimate knowledge of the health care system and who have always been extremely interested in participating in and improving that system.

SEIU generally supports the five objectives of community service reform as outlined in the act. But at the same time, SEIU is concerned about the number of items and details that have been left to regulations and guidelines. For example, persons requiring care will be assessed by an agency which will determine the type and amount of care they will received. What this will be based on is not defined.

SEIU is concerned about the lack of choice for consumers as to whether they live in a community or institutional setting. While many people do not want to live in an institution, the alternative can be just as undesirable. The objective of the long-term care reform should be to respond flexibly to the individual consumer's needs. Resources in the system should be able to move where individual needs dictate. The system should respond to people's choices and not unnecessarily lever what choices may be made.

SEIU is concerned with the emphasis placed on the volunteer within the community-based system. Without defining standards of care and proper training expectations, it will be difficult to obtain a reliable level of care for consumers.

SEIU is concerned that this initiative does not live up to the five cornerstones of health care as set out in the Canada Health Act. It is possible for a person to be refused access to community care under Bill 173. The act does not define the basis on which this decision would be made. Whether it would be based on need or on the agency's budget is not clear. Bill 173 also indicates that not all services will be paid for by the government. The compendium states that government guidelines will ensure that consumer fees do not present a barrier to community living. The way to ensure this is to have no consumer fees at all.

SEIU is concerned that the reform will place more expectations on family care givers and volunteers, most of whom are working women. To expect them to now shoulder the burden of increased levels of care is unjust. If the reformed system is not to exploit women, a range of supports for family members who choose to be care givers must be provided.


Volunteers were always meant to be a complement to the system, not its mainstay. No one knows whether the numbers of volunteers the reform envisages will come forward. Many volunteers are senior citizens themselves. To avoid exploiting them, the reform mandated by Bill 173 should invest in job creation and be less concerned about saving money.

District health councils are and will be required to play a vital and expanded role in the restructuring process. Given the importance of the DHCs' role, SEIU, through the Ontario Federation of Labour, has argued for a total of four labour appointees on each DHC: two as consumers and two as providers. Under the Social Contract Act, the health sector agreement provided that DHCs should include people who bring a labour perspective. Labour has also taken the position that it should have the right to select its own candidates for appointment.

Although SEIU acknowledges that these are volunteer organizations, it has also requested that the Minister of Labour provide the DHCs with sufficient resources to ensure that members be reimbursed expenses and lost wages incurred as a result of DHC duties. If the consumers and providers from the grass roots are to be real participants in the process, this must be done.

Such involvement in the DHCs would fulfil promises of full participation. These same standards of participation should be applied to multiservice agencies.

SEIU supports the safeguards and protection the government has included in Bill 173 for the consumer. However, we strongly believe that consideration for the wellbeing of the workers providing the service is equally important. Indeed, we believe it is critical to the consumer and should be safeguarded and protected in the same way.

At the time of SEIU's submission on Bill 101, we had four units of homemakers in a strike-pending position. Two units of the Canadian Red Cross Society went on strike. It was a long and bitter 14-week strike. These workers earned in a range of $8.47 to $9.57 an hour but few if any of these workers ever worked more than 21 hours a week. As one of the workers involved in the strike put it: "For six years, I have been going into the homes of the elderly and disabled in our community and providing housekeeping, laundry and personal care services. During this time, I have not received any of the basic benefits given to other health care workers. At what point do I say, `enough' and start looking after myself?"

Eleven days after the strike began, the Red Cross announced it was closing its homemaking operations in Dundas and 40 employees were thrown out of work. They never did get their jobs back.

SEIU believes that the local home care program's actions in continuing to refer cases to other service provider agencies, which in effect scabbed during the strike, are reprehensible and send a clear message to workers that they will be punished if they exercise their right to strike. It also says to the employers of homemakers that they will be discriminated against in the referral of cases because they have unionized homemakers.

The Ontario Labour Relations Board was unable to protect the striking homemakers from being replaced by scabs because of loopholes in Bill 40. However, the board stated in its decision in a case brought before it that it found this result "troubling" since it "emptied any real meaning from the right to strike and hence bargaining rights."

SEIU recognizes that this issue cannot be addressed in Bill 173, but the point must be made: Workers in the community-based sector of the health care system have no protections.

SEIU acknowledges the difficulty of reopening the Labour Relations Act, but as an interim measure, it has recommended to the government that the Red Cross Society and all other employers of homemakers be declared a health institution under the Hospital Labour Disputes Arbitration Act. This would give homemakers the same mechanism that institutional care providers have that ensures that their terms and conditions of work can be settled fairly and equitably by an interest arbitrator.

SEIU believes there is a correlation between quality of care and skilled, trained workers who receive adequate pay and benefits, job security and the knowledge that their employers value their work. This is even more important in community care, where the worker is going into the consumer's home and works independently on a one-to-one basis. But is the issue quality of care or saving money? The compendium is quite straightforward concerning the government's goals when it states that lower-cost workers should be used wherever possible.

Since the beginning of this reform process, the government has been looking into the creation of a new classification: the personal support worker. The intent was to combine classifications already in existence. This would require health care workers who have struggled to attain qualifications, such as the health care aide certificate, to be trained again in order to retain their job or, if displaced within the sector, to apply for a job in the community setting. Is the government going to pay for this or are the health care workers supposed to find the tuition and time on the meagre salaries they already earn?

If lower-cost workers are to be used, does this not mean fewer RNs and RPNs will be used? Just such a scenario took place in St Joseph's Hospital in London when the registered practical nurse and the nursing assistant classifications were declared redundant and are being eliminated in favour of a new classification called the primary care partner. Rather than be laid off, these qualified people chose instead to work and earn $3 to $3.50 per hour less, with increased workload and no recognition of health care credentials. In fact, the union submits the job hasn't changed substantially. The RPNs may do a little more housekeeping and dietary work and no charting, but they still do the basic bedside care. The issue is still in dispute, but morale is at an all-time low and quality of care will not be furthered by this exercise.

Finally, health care unions have been lobbying for a provincial comprehensive, enforceable employment security agreement that would facilitate the redeployment and retraining of workers displaced in the health care sector. SEIU believes that a single province-wide approach is a practical method of dealing with the problem of displaced workers. The health sector training and adjustment program, which is bipartite in nature, would be the ideal mechanism for keeping track of available jobs and available workers. With so much change happening in the health care sector today, a province-wide employment security agreement makes sense.

In conclusion, a glaring omission from Bill 173, which sets it apart from the initial Partnerships papers, is that the government has abandoned any notion that labour should be a part of the process. Indeed, the workers have been abandoned altogether. The health care system is dependent on health care workers. To a great extent, they are part and parcel of the system. They must be given a voice, they must be given decent wages and working conditions and job security. They must be given some respect.

Without assurances to the contrary, SEIU concludes the real objective of Bill 173 is saving money, not maintaining people in their homes.

Mr Tony Martin (Sault Ste Marie): Thanks for coming forward today and raising some of the very legitimate concerns that you do. It's certainly interesting to hear you state that in fact unionized workers and workers will be hurt through this exercise. We've been criticized through the piece that this is an effort to unionize the whole delivery of long-term care, so we get it from one side and the other, and I hope you'll understand the confusion that it sometimes causes in us as we grapple with this.

Certainly, it is our intention, through this legislation, to bring the best that's out there re workers to the equation and to have them participate with us in putting in place in Ontario the most comprehensive and professional service we can offer to people in the province who are in need of long-term care.

The question that always comes up re the use of paid workers versus volunteers, that argument that you've heard and we've heard, the concern, is cost. Your allegation here is that this is an exercise in trying to save dollars, when the reality is that we're putting more money into this. We just want to get the best service we can for the money we're putting in. Maybe I could have some comment from you on how you see us achieving that end, while at the same time recognizing that we need to be including as many of your members and members of other union organizations who are already in the field in significant ways in this exercise.

Ms Marcelle Goldenberg: I think our first statement is that it can't be in terms of savings, dollars, at any cost. If you're looking at substitution of unionized labour versus the other extreme, which is the volunteers, you're doing it at the detriment of the residents and of the patients. I don't think that's what the objective of the government is in promoting this particular piece of legislation, or overall in its reform of health care.


If you want to look in terms of cost, maybe we should be looking at the duplication of services that are provided, the administrative costs that are duplicated from one agency to another and the saving that would be realized, perhaps, looking in those particular areas.

In the community services sector, our members are not exactly highly paid members. We're quoting Red Cross workers, who are unionized members, making $9 an hour on average, whereas the average industrial wage for the rest of the province is something close to $13 an hour. We're not looking at high-cost employees working in the community-based services at this time. Is that correct? So we shouldn't be looking at the workers who are providing the services to the residents, to the people in the community, as a mechanism to reduce the costs overall in the system.

Mr Martin: I'm assuming, in your recommendation that we put in place a plan re the workers who are already in the system, union as well as non-union, that you include in it that we need to concern ourselves about all the workers, not just the unionized sector?

Ms Goldenberg: Of course. We happen to be more heavily unionized in the institution sector, at this point, between our hospitals and our nursing homes. It's not heavily unionized right now in the community-based services sector, but any redeployment system in terms of a shift must look at all workers, whether they be unionized or not.

Mr Martin: You say here in your brief, "SEIU believes there is a correlation between quality of care and skilled, trained workers who receive adequate pay and benefits, job security and the knowledge that their employers value their work." I certainly couldn't agree with you more. That's something that we as a government, in every sector, certainly believe in and ascribe to.

We just had presenting, before you, the CUPE representatives. When we move into this -- I don't think I'm speaking out of school when I say this -- we do intend to have a high level of organized labour involved in this exercise. How do we sort out the jurisdictional question of what union represents what workers and that kind of thing? Do you have any thought on that?

Ms Goldenberg: I think most of organized labour is members of our affiliates at the Ontario Federation of Labour, and we're very encouraged to hear that there'll be increased union participation and input in the process. I think the least of our problems is going to be in terms of jurisdictional issues, which unions get to comment or be involved. I think the most important thing that we have to recognize, and we haven't seen it in previous submissions or in responses from the government, is that labour has a very important role to play, and it is one of the stakeholders that we need to hear more from. I'm sort of encouraged by that. I'm not so worried that there would be issues and sorting out who gets to be involved.

I think probably channelling most of the information through the OFL, which represents most of the organized health care unions in this province, would be the same as perhaps going to the Ontario Hospital Association to get feedback from a hospital point of view, because they are the umbrella organization for all the hospitals.

The Chair: Thank you all again for coming before the committee and for your presentation.


The Chair: I call on the representatives from the Ontario Association of Non-Profit Homes and Services for Seniors. Welcome to the committee.

Mr Dan Oettinger: My name is Dan Oettinger. I'm president of the Ontario Association of Non-Profit Homes and Services for Seniors. My colleagues here are Kevin Mercer, who is president-elect, and Michael Klejman, who is our executive director.

On behalf of the association, I would like to thank you for the opportunity of sharing with you our views and opinions on this piece of legislation, Bill 173, which we believe is very important to the citizens of Ontario. May I also express our appreciation for extending these hearings and allowing other groups, ours in particular, to come and present to you today.

Before we summarize our views, I'd like to make an observation. As an association of service organizations, it's entirely possible that we've been characterized as a rather narrow-focused self-interest group. Should that be the case, there sometimes is a tendency to dismiss what is said as self-serving. However, because we are very convinced that the future of long-term care hinges on the decisions that you folks make here, the advice given to the Legislature, I'd like to urge you, encourage you, to take an unbiased and fair view of what is presented and the information that you gather in these hearings.

We at OANHSS, I submit, are not self-serving and not in the long-term care business for our own benefit. Our volunteer leaders of our member organizations are involved because of their commitment to the health and wellbeing of others. They make no profit for their efforts.

In addition to that, our leaders are grass-roots community people and they have a good knowledge and understanding of what's happening at the community level and are therefore, we believe, in a good position to respond to you on the needs in the long-term care field.

We've waited a long time for an opportunity to discuss and create a new way of delivering services to those who need supports on a long-term care basis. We compliment the government for pushing ahead, in spite of the very negative economic conditions, with this restructuring. However, we have some very serious concerns about how that restructuring is happening.

OANHSS, as a representative of the non-profit facilities sector as well as other care services, has been in the forefront of support and encouragement for the government to reform the system. We advocated for and supported the principles of redirection long before they became a reality.

Today we'd like to share with you our views on what needs to be changed in the proposed Long-Term Care Act to ensure that it stays on track with the principles of redirection laid out by this government three years ago. I would echo some concerns expressed over here a while ago: I suspect if Mother Teresa were here she would have the same concerns that we do.

We have provided you with documents -- I believe you have them now, the full submission -- which include specific recommendations for amendments to the bill and a summary of our views and recommendations. In the next few minutes we'd like to highlight those views and recommendations for you, and at the end hopefully we'll have time for some questions, if you wish.

Michael will walk through those concerns for you and Kevin will summarize our position for you.

Mr Michael Klejman: Here are some key points I'd like to share with the committee, and also I'll make reference to the amendments that we recommend for the committee's consideration.

We feel that this bill has drifted away from the principles of redirection stated by the government in 1991. Those principles spoke to flexibility, consumer choice, integration, effectiveness and client focus as being central to the process of redirection.

We find in this bill a high degree of inflexibility which has sacrificed the principal point of seniors and others who require long-term care and replaced them as the essential focus with the development of the multiservice agency model, which is rigid and prescriptive in its current description in the act.

Consumer choice has been replaced by what I would like to refer to as a monopoly service that will decide who needs what service and then provide that service.

Instead of the integrating of services that we had hoped for, we see continued separation of health and social services in an artificial way, at the same time wiping out the wealth of services that in some cases took decades to develop in this province.


The desired accountability is replaced by an MSA which is beset, we believe, with a basic conflict of interest. When financial resources are limited, which agency will not opt to maximize its revenue at the expense of giving consumers the most appropriate, for them, services? Funds will be directed to a multiyear process of developing MSA-type agencies, forgetting about the principle of cost-effectiveness.

Let us be clear: We do support the principle of restructuring and elimination of the multitude of small one-service agencies through amalgamation of service providers into comprehensive administrative units. But we do not believe that that process should be willy-nilly, should be arbitrary and without consideration of the quality and effectiveness of the existing system.

We also see the loss of client focus in this bill. That is probably the most disturbing to us. The focus in the bill is very clearly on the MSA, the multiservice agency, not on the consumer who is to use the service.

If I may draw your attention to some pages in our full submission which contains our amendments, I'd like to just make a brief reference to the areas that we address in our amendments.

On page 13, we identify the purpose section of the bill and specifically recommend some changes which will broaden the intent of the bill.

Part 2 of our recommendations deals with the segregation of services as contained in the bill, and again we recommend some deletions and substitutions in one of the sections.

We also address, on page 14, the issue of governance, an issue of great concern to our members, and recommend some changes to provisions in the bill which will recognize the role and also allow a fairer process of selecting organizations which will act as coordinating bodies. We also recommend changes under service definitions on that page and then, on page 15, we speak to the financial controls and funding provisions.

The Chair: Could I just interrupt, because I think everybody is doing what I am doing, and that is saying, "Where is page 13 and following?"

Mr Klejman: Sorry. Building the Framework or Controlling Delivery is the main document.

The Chair: We go to page 12.

Mr Klejman: So you do not have the complete submission.

Mr O'Connor: The Coles Notes version.

The Chair: Which is fine as long as we get it.

Mr Klejman: I'm sorry, Mr Chairman, our submissions were delivered here on September 13 and there were two documents left here at that time.

The Chair: Okay. What may have happened is they're sitting in an office.

Mr Klejman: You probably have them in your files but you did not get additional copies today.

The Chair: If you want to draw reference to those, that's fine, but I just thought you might be wondering why we were all sort of scurrying around here.

Mr Klejman: I will leave the copy that I have with me today, just to ensure that the committee is provided with, to us, the most critical section because that contains the amendments we propose.

I'll stop at this point because I think what's more important is for us to have a chance to answer some questions.

The Chair: Perhaps you want to just highlight some of those because, unfortunately, with the number of presenters, we can only have one questioner, and I think you may want to, on the public record, note those and then that also gives us something to use. As we go back and look at your specific recommendations, we can follow that through.

Mr Klejman: I'd like to draw your attention to part XII of the bill, which speaks to the powers of the Minister of Health to assume responsibility and control over, in one section, municipally owned and operated homes for the aged and, in another section, charitable homes for the aged.

We believe it's a significant broadening and expansion of powers that were originally contained in the Ministry of Community and Social Services Act and we're asking that that be reviewed and amended to recognize the legal responsibility and authority, on the one hand, of the governing bodies of those facilities, and not limiting or taking away from the minister the responsibility to ensure the wellbeing of the public that is served through those funds, but also to ensure that there is a more impartial and fairer process to determine under what authority and for what reasons those powers are being exercised.

Mr Kevin Mercer: Just a few concluding comments: In our opinion, Bill 173 introduces significant change without truly appreciating the consequences of this change, and in this regard it's worth reflecting for just a moment on the experience we have had in the past 14 months since Bill 101 has come into effect, and I would direct you to page 3 of our submission in that regard. In a nutshell, the promised $206 million did not materialize and the new regulations on user fees have confused residents and not generated the promised revenue. The highly touted levels-of-care funding system has almost totally been dismantled, and the administrative workload for facilities staff increased while in homes for the aged, staffing and services suffered.

It is our hope that this committee will generate recommendations for amendment to Bill 173 in accordance with the OANHSS submission and the several other submissions that we're aware have been presented to this committee. As Dan mentioned in his opening comments, we are a grassroots, non-profit organization that has a genuine concern for the future of long-term care in this province. In terms of the proposals in Bill 173, those concerns are heightened.

The future, in our opinion, rests in building on current strengths in the system and not a dismantling of the system, and we are certainly prepared to work with the government in that regard.

Mrs O'Neill: You're one of the few who have actually talked about Bill 101 in these hearings, but certainly people who I've talked to outside these hearings have compared the two bills, and one certainly doesn't set the most comfortable environment for the other.

I just wanted to verify that you said that Bill 101, in addition to the things that you've suggested -- and the one that most concerns me is the mixed messages that are going to residents, and sometimes directly to residents -- that administrative work has increased, I think you said, and I certainly have had that verified in other environments, and that the front-line service providers have been able to do less. Did I hear you correctly? Is that due to other things such as expenditure control and the social contract and then Bill 101?

Mr Mercer: You're correct. There are a number of factors that have impacted and have presented themselves as pressures on facilities, but we would include in that inventory of pressures Bill 101 as well, that the administrative workload has increased as a direct result of Bill 101.

Mrs O'Neill: And service providers in some ways have been cut, either hours or that which they can do? Is that what you said? You gave a second caveat.

Mr Mercer: I would not directly say that it is due solely to Bill 101, but it is a contributing factor, for sure.

Mr Klejman: If I could just say one other point, we have also experienced shifts in the funding structure, so besides the question of whether the full $206 million has materialized or not, there has also been the process of changing the way the funding is working in the facilities sector, and we have experienced losses.

Some of our members have gone through layoffs, reductions in hours, cuts in service, and that was part of Kevin's reference, that while resources are not there to the level promised, and we hope that they will come through eventually, at this point many of our members -- and we just attended a meeting, a special session for residents of our facilities today, 300 of them, and staff and volunteers who came with them were all saying to us that they have seen staff reductions, staff loss, deteriorating morale, particularly in those facilities that have been, in the past, touted as examples of quality care.


Mrs O'Neill: Okay. Many people who have come before us have suggested that they are guilty of being self-serving. I'm sorry, I don't agree with that, and I certainly am glad you've come.

I wanted to go to a couple of areas. You talked about this bill going to have little to do with quality of life; I think you also used client focus as being lacking. I'd like you to say a little bit about that, in the first part of my question.

The second part of my question: I presume that in some of the facilities you gentlemen are responsible for there are day programs that will somehow hopefully relate to the MSA. Would you say a little bit about both of those things: how you feel quality of life and client focus could have been improved in this bill, and what you see your relationship is to the MSA?

Mr Oettinger: If I could respond to the one part of your question and I'll let Kevin respond to the day program question, because he's more involved with that than I am, we see in Bill 173 a great deal of focus on the MSA per se as an agency as opposed to the services required by various groups of people in the community, and a great deal of lack of focus on their needs and their services and rather a focus on what the MSA will do and what it will not do. There was reference a while ago to the 10% or 20%.

Mrs O'Neill: Could you give a couple of examples of what you really think has been overlooked?

Mr Klejman: Let me just quote one proposed amendment that we put forward, which we feel puts the emphasis or focus on the consumer. In the purpose section of the bill, we recommend that an addition be made that reads:

"The purposes of this act are,

"(a) to recognize the person's needs as the most important factor in managing and delivering community services, and individual preferences as another major factor."

That kind of emphasis or strength is not there in the bill right now.

Mr Oettinger: To simply set a finite level of services that must be provided by the agency, the MSA per se, and may not be purchased outside is to focus on the MSA as an organization rather than the client. Rather, we need to find out what the client needs and get that service, wherever it may be, by whomever it may be rendered, to meet the client's needs, not setting a limit on who will do it or who will not be permitted to do it.

Mr Mercer: We would suggest as well that one of the major difficulties in the long-term care system has been awareness of access and how people obtain information around services that are available. We believe that in terms of reforming the system, that problem has been overstated in terms of the general system and that the MSA is looking at the creation of structures that centralize as opposed to building on the strengths of the community delivery system that has been developed over an evolution of years and is based on good, solid community values.

Mrs O'Neill: You were going to say something about your day programs.

Mr Mercer: In terms of day programs, it would be our opinion that they should not be included as part of the MSA, that there's no reason why they could not be kept outside of the multiservice agency. They operate as a continuum of care quite often with facilities and there's no reason why they can't function and operate quite well in that regard. I guess we would present that argument for a number of the community agencies, that there really is no rationale, no documentation that we have seen, that would indicate the benefits of the centralization that is proposed.

Mrs O'Neill: In the first week of the hearings we had some discussion about this. I think it was in Hamilton. Has there been any more decision-making around that area regarding community or facilities with day programs and their relationship to the MSA by the government?

Mr Wessenger: There certainly have been no further decisions made with respect to that matter at this stage.

Mrs O'Neill: So there's no consideration of exemptions for existing day programs.

Mr Wessenger: Well, there is consideration. There are a lot of items under consideration. I just wanted to indicate that no decisions have been made. There's the different matter of what one is considering and what one is deciding to recommend.

Mrs Sullivan: That's a pretty fair commitment to eliminating the day care programs that were provided by facilities from the 80-20 formula.

The Chair: Mr Klejman, did you wish to comment?

Mr Klejman: Yes, I do, and maybe I'd like to come at it from a slightly different perspective. What's unique to our sector, the non-profit sector, has been a strong philosophy and practical efforts to develop what we call continuum-of-care models. These are environments where seniors live when they are totally independent, in independent housing settings, and if their needs change, there are other resources available to them, day programs being one such resource.

One of our concerns, and I know it wasn't the intent of Bill 173, but the impact of this will be fragmentation, in some cases dismantling of these continuum-of-care concepts, where to access one service or another service will be a decision of an MSA, not of the organization or the person who is living in that community and using those services.

Mrs O'Neill: Several have brought that to our attention.

Mr Jim Wilson: Mr Chairman, If I can just say, this is one of the most comprehensive briefs I've seen, and I hope the government takes note of page 8, where it lists the litany of costs you've imposed during your term on these homes. I'm surprised there's any money left in the system to actually look after residents. I hope you take a darn good look at their analysis of Bill 101 and the litany of new costs you've imposed on this system, because this is one of the best comprehensive set of Coles Notes I've seen, and you'd better bloody well take a look at it.


The Chair: Order, please. Gentlemen, thank you for coming before the committee. I should note for committee members I believe, Mr Oettinger, tonight you step down as president and Mr Mercer becomes the president. I was going to inform the members. I don't know whether that means you turn into a pumpkin or just what happens.

Mr Oettinger: I'll be around for a little while longer.

The Chair: I'm sure you will and we wish you well, and also Mr Mercer in your new functions as president. Thank you again for coming.


The Chair: I invite the representatives from the Ad Hoc Consumer Coalition on Long-Term Care to come forward.

Ms Patti Bregman: You're just going to have me. You're stuck with me.

The Chair: That's quite all right. I was sort of expecting a larger group, but you're more than welcome.

Ms Bregman: My name is Patti Bregman. I'm a lawyer at the Advocacy Resource Centre for the Handicapped, and I'm here alone. My colleagues apologize; they've been tied up at other meetings, which are ongoing, about long-term care.

We decided in August that the consumers needed to be heard from more effectively, because basically, and we've been following Hansards, there has not been a strong consumer voice before this committee, and we brought together a group. The list of the groups that formally signed on is attached, and there are a number of other groups around the province that I've spoken to since. I just got back from London this morning. We wanted to show that you can bring together consumers who represent people with AIDS and seniors and people with physical disabilities and people like myself who've got invisible disabilities. I've been on the home care system for eight years now. I consider myself extremely fortunate to have benefited from the system and cut my hospital days from six months to less than 30 in a year, and I think that's quite remarkable. We wanted to address the key issues, as we see them, from the perspective of the consumer.

We will not be addressing the issue of the multiservice agency. There are a number of complexities in that.

To be honest, from our perspective, there's not a whole lot of choice in the system right now. Despite what we hear from service providers, in the eight years I've been on long-term care, I have never had an option about where I get my services and who I get them from, and sitting as a lawyer who deals with a lot of people who come in to complain about the system, I also know there are an awful lot of people in this province who not only don't have choices but have services cut arbitrarily, decisions made for them that are inappropriate. So we're presenting in that context.

I think what we've looked at as the focal points are the consumer protection and strong bill of rights, the complaints process, quality assurance, the regulation-making process and the accountability of the district health council, which, as I've travelled in the last month, is giving me increasing cause for concern. There is a great deal of disparity in terms of how they act. I will not go through all of this. I'll try and highlight those areas in particular where we are making specific recommendations.

We think the bill of rights is essential and are extremely pleased that the government listened to us on the bill of rights and made it something that is actually enforceable. We've seen what's happened with the nursing home bill of rights, where it's very difficult to enforce. This will finally give people some power to go out without having to rely on the government to intervene or without having to rely on a service provider to suddenly decide, "Yes, we'll agree." In all of the system, we've got labour, which has had a very strong voice, we've got service providers, who have a strong voice, and the government, all of whom have contracts with each other, and the consumer isn't party to any of them. We think this bill of rights will start to address that disparity in the power relationship.

We're really pleased that it covers all service providers, not just multiservice agencies. There will still be services provided by other agencies and there should be no difference in the kinds of rights that are provided.


We're also extremely happy about the provisions preventing harassment for people who complain. We dealt with a situation in Windsor, which I think all of you are aware of, where clients who complained were forced into hospitals, were evicted, were threatened with withdrawal of services, to the point where the ministry had to take it over in April, and for that we were extremely grateful. That shouldn't have to happen. This will hopefully give them some protection.

Finally, we'd like to add a couple of things to the bill of rights. One deals with information. We're glad that throughout the act it talks about having to provide information. That's been a major problem for a lot of our clients, that they just can't find out what the rules are that govern the providers. But what we would like to see added specifically is that the information be provided in accessible formats, in Braille, on disc, on tape, and in plain language, because handing somebody who's blind a piece of paper they can't understand is not providing them with information, and unfortunately it's our experience that unless we specifically say it must be accessible, we won't get it. For example, I can't get this piece of legislation in an alternative format, which means there are all kinds of people around the province who cannot participate. That's an extremely serious concern from our perspective and needs to be addressed in this legislation.

The other area where we have some concerns deals with abuse. We are getting an increasing number of calls from clients who are forced to receive intimate services from attendants or service providers of the opposite sex. This can't continue. For obvious reasons, people with disabilities are extraordinarily vulnerable. In some cases, they can't speak. We've had a number of cases recently where even after a client was raped by a provider, they were still forced to have a male provider. Unions have taken the position that they can't be forced to go to only one gender; it's taking away their experience.

That's not acceptable, and we would like it added to the bill of rights that there is a specific provision that says you may choose the gender of your provider where it's intimate care. Obviously, if it's a homemaker, there are situations where you don't need the choice, but where somebody is vulnerable, you're going to the house, you can't speak, we need to have that.

Consistent with that, we would like an exemption from the 20% brokerage restriction. An MSA may not be able to provide the same-sex provider, and we need to make sure they can't say, "Oh, well, the 80% rule holds us in." We'd like that to be made an exception, that where either there has been abuse or where you need to have somebody chosen of the same sex, that is exempt from that restriction.

In terms of enforcement, it may sound strange coming from a legal clinic, but we would like to see some middle ground in terms of ways to enforce both the bill of rights and complaints process. We don't think lawyers are the appropriate people to intervene in every case, and in fact I think in a lot of cases lawyers are probably not the best people. The Advocacy Commission will be able to help to some extent, but we would like to see the government consider putting in some provisions for alternative dispute resolution, mediation and provide for the funding, because right now we do have mediation going on, but it's usually with volunteer mediators, and I think that's unfortunate, because it will save a great deal of money. We don't think you need to start in an adversarial position. You may end up there, but that is not how we want to see it.

On the other hand, where there are serious breaches of the bill of rights, we also don't want people to always have to go to court and would like the legislation amended to specifically provide that where there has been a serious violation of the bill of rights, that is a specified grounds for potential revocation of an approval or a designation of an MSA. If we're seeing consistent violations, it shouldn't mean that every single one of those clients has to go to court before the ministry takes a look and says, "No, that's contrary to the act." You need to be able to step in.

We also would like service providers to receive some education and provide education for their staff on sexual abuse, and we think this is extraordinarily important. The government has recognized this within the context of the regulated health professions. A lot of the providers in the system will not be governed by that, and we do think it's an obligation of the government to both require it but also to provide subsidies to those providers who are going to have to add on another piece.

In terms of quality assurance -- I'll skip over to that on page 9 -- again we're pleased that there's a provision, but it's extremely vague. I guess what we don't want to see happen is a bureaucratic quality assurance program of TQM or CQI or whatever the language is. The AIDS community has been extraordinarily effective in working with consumer-driven partnerships with providers to develop the standards that are going to be used to measure, to be participating in the evaluation, and I think what we would like to see here is some specific provision, whether it's in the regulations or the legislation, that says that quality assurance (a) will be independent and (b) will involve the consumers of the service along with the providers at every stage in setting standards and evaluation and in discussing what it is you do with the information at the end.

We don't see quality assurance necessarily as having to be punitive, but something has to come out of it. It should not be something we just do for show. Information has to be available. We need to use it to find where there are problems in the system.

I was speaking last night to the London Cheshire Homes Foundation at their annual meeting. They're starting a new quality assurance process that involves all of them, and they see it as a dynamic process. "This is how we'll see what will happen with our services in the future." I've given you an article that kind of puts together some of that perspective, which I thought you might be interested in, just for your own time.

Finally, two other areas: One is the regulation-making process. I think you've heard before there are concerns that so much of this legislation is left to regulation. I can understand the need for flexibility, but I'm very concerned about the lack of accountability, so what we're recommending is that, number one, there be put into place a permanent form of an advisory council that would have joint representation that would have the mandate for reviewing all regulations and that, like the Regulated Health Professions Act, there be mandatory public consultation on the regulations so that we don't wake up one morning and find out that we've got user fees, or we don't wake up one morning and find that eligibility criteria have suddenly changed. We need to have it in the legislation.

There has got to be some kind of public accountability and public process so that we're aware and we all know who to go to and talk to. Right now there are a number of internal government committees. I can't tell you who's on them. I've asked, and I'm sure I'll get an answer, but we need to somehow formalize that process so that the community can connect, service providers can connect and there's some more certainty in the system and we're not all running all over the place. There's a lack of coordination right now that I think needs to be addressed.

Finally, in the area of governance, we're pleased about consumer representation but somewhat disturbed that there's no definition and no specific requirements. What we're proposing is a definition that would basically say it's people who are currently using the services or within a short period of time of using the services. There is a very different perspective. While all of us may at some point be consumers, I can tell you from my own experience, it's quite different. I know what it's like to wake up in the morning and the nurse doesn't come, or if I get cut off the program or if they change it.

I think you need that perspective there, in part to keep it practical. I think a lot of people who use services are very good at telling you how to save money on services. I think they see the overbureaucracy, they see the administrative costs, and they need to be part of that. So what we're recommending is that you don't have consumers who are also service providers. We think it's a conflict of interest. We know of district health councils that have appointed retired doctors as "consumers," and we think this needs to be addressed.

We also think there needs to be a mandate in there requiring accommodation. We have people who can't get to meetings. It's great to have consumers, but if you have meetings at times people can't get to, if there's no transportation, if they don't have the time and the expertise to read the material and prepare -- and you have to recognize, these are people who do not do this for a living. I do it for a living, so I read the thousands of pieces of paper that come over my desk.

What we need is to find a way in which people can truly participate. We don't need a lot of committees, we don't need hundreds of meetings, we're not suggesting that we want to spend all our time in meetings, but we need the district health council to have a mandate.

The Metro DHC, for example, does not have a telephone device for the deaf, despite it being raised with them, and that's just not acceptable. I've found as I've travelled the province that there are accessibility problems. Information's not provided in accessible formats.

So I think that's going to have to be in the legislation, or at least in regulation, that one of the requirements of the district health council is one third consumer representation, using a definition that is truly a consumer, but also a positive obligation. Right now they're getting a lot of money for consultants. We think some of that money has got to go back to the community.

The Chair: Thank you very much, and I'd just underline that your brief goes into far more detail than you have been able to, and also the article you have appended to it on the quality-of-care paradigm.


Mr Jim Wilson: Thank you, Ms Bregman, for your presentation. I think you've got a very good brief here, and it's very comprehensive. I particularly appreciate your latter comments about district health councils. The title of the point is "The accountability of the district health council," and I know you're trying to improve accountability by improving consumer participation and representation on district health councils, but I'll tell you, I travel the province. I'm not sure that's going to cure things --

Ms Bregman: Oh, I agree with you.

Mr Jim Wilson: -- just adding more consumers, because it seems to me our district health councils are getting into a group-think mentality, no matter who gets appointed to them, and I'm quite fed up with some of them in terms of their being perceived as fronts for government policy now, rather than what they were originally designed for, which was to be the ears and eyes and spokespeople and advocates for the communities that they're there to represent. They're not to be front shops for government policy, which is what I'm running into in a number of parts of the province.

Just so you'll know, I want you to comment on that, because I'm not sure just adding more consumers is going to improve what I think has been -- and I don't blame the people, and the good people, who volunteer for district health councils; I blame the government and the way they've been used -- the way they've been used in the Legislature -- as political crutches and fronts for government policies. Can you just comment on that?

Ms Bregman: It's a hard one to comment on. I don't think just putting consumers improves accountability. I think there are things like open meetings and ways of dealing with it. In essence, regardless of whether they're speaking for government policy, devolving something off assumes they are going to be making the policy decisions at some point, and I think there is going to be this tension. At the moment I'm not quite sure what the answer is. One of the things we're about to embark on is in fact developing a consumer network to monitor what's happening at the district health councils.

Mr Jim Wilson: Well, that's a good idea, because I just got off the phone with central Ontario district health council people who are doing a dialysis study and I'm told everything's secret.

Ms Bregman: Yes. Exactly.

Mr Jim Wilson: What the hell are things secret for in a district health council?

Ms Bregman: Well, in fact, in the MSA proposals, in one district health council consumers are not allowed in the door. That's a very serious concern. I can understand they don't want "constituencies," but when they tell consumers, "You're here just for yourself; you don't tie to anybody," we think that's a problem. It's not that we expect all of them to take the same position, but our approach is, we did this brief with no money. We're probably the only group in this entire process that has absolutely zero dollars to do this.

Mr Jim Wilson: Congratulations.

Ms Bregman: Well, it's good, but it also is a problem. But what we're struggling with is, how can we effectively communicate with those consumers so that they understand the issues at the grass-roots level, because I think the way to make the district health councils accountable is to make the members accountable. It's not going to be something the government can do or say. I think we have to go to the members and say: "We're holding you accountable. You're there." I think that's the way things are going to devolve and change. So I think it's going to have to come from us, and we're just looking for mechanisms that will allow us to do that right now.

Mr Jim Wilson: I really appreciate your comments along that line. I have one more quick question, and that is with respect to the bill of rights, because you did give us some comment on that, and extensive comment. As written, it's a deemed contract. Can you give me in layman's terms, if the bill were to go through now, is there any other mechanism in there other than resorting to the courts? There's the appeal process along the way, I suppose, but are there enough teeth in there now if the bill were to be passed as drafted?

Ms Bregman: I'm not sure you could put much more in, to be honest. I think, if we have the question of whether or not their approval is subject in part to this, which I do think needs to be added specifically, and if we can develop some kind of complaints process that really works, that's independent, and I think we've recommended that there need to be stages of that, then I'm hoping that that, combined with advocacy, will enable the people to feel more comfortable.

A lot of providers are fine. Many of them are good. But the ones who aren't -- and we now have a number of quite serious complaints -- I'm hoping at least if they see that people have rights, people will now become more empowered to work with tenant groups, for example, or form their own little groups to try and sit down with those in power, sit down with the government and work it through. What happens now is, consumers will not get together and organize, because if they do, they're harassed. So what we see is this freeing some of that up.

I'm not sure you can put it in legislation without it becoming very cumbersome. I think it will be a very flexible process, but I think the more we make these organizations accountable and the providers accountable and they know people have rights, part of what our job is now is to educate the consumers about what those rights are and give them some suggestions. I think a lot of the organizations in the disability community are starting to work on that, to help people develop things, and work with service providers and get them to change and develop processes that are accountable.

The Chair: Thank you very much again for coming. While we're sorry that your colleagues weren't able to be here with you, you have represented their views very well, so we thank you.


The Chair: I'd like to then call on the representatives from the Ontario Association for Community Living. Welcome to the committee.

Ms Cheryl Easton: My name is Cheryl Easton, and I'm the president of the Ontario Association for Community Living. I would like to introduce Jim Mahaffy, who is our first vice-president, and Barbara Thornber, who is our executive director. I will be sharing this presentation with Jim, who is the chair of the promoting community living options task force. This has been something that has been very central to us for over 20 years of our 41-year history as an advocacy group.

Today our grass-roots membership is over 15,000 and we are a federation of 115 locals whose budgets are anywhere from $500 to over $40 million, so you know we're just slightly diverse. We work on behalf of and work with people who have intellectual disabilities or who are labelled that way. We're also very much in concert a lot of the time with People First of Ontario. We join sometimes in coalitions and other times we're fighting, but that's okay. We respect one another's opinion and who we are.

Since the early 1970s we have successfully integrated or brought back from institutions 6,000 people, some of whom were deemed very hard to support, and we have done it. We were not good at the beginning; we're better now. There are still another 2,000 people remaining in institutions of the estimated 30,000 people that we support.

Today, spending on developmental services in Ontario is just under $895 million.

Despite our successes, there are fundamental problems with our present system of delivering community services for people with developmental handicaps. The system within the community is in itself a form of segregation. We tend to have people phone and say, "You're the experts." Well, we're not the experts on people, because people are very diverse. As you and I live in a community and want our rights respected and want to be a productive part of the community, that's all we're asking for people we're advocating on behalf of.

What we do with group homes and other things is an institutional practice in itself. We're developing programs and then putting people in them according to their label or "functioning level" or a whole bunch of other really ugly terms that I don't ever want to be associated with myself.

Now I'll talk a little bit about our interest in long-term care reform. We understand that people with developmental disabilities have not been included in the current reforms, which is very upsetting. We have prepared these comments that Jim will give you on the future reforms to the system of delivering community services to people with developmental disabilities.

We are seeking a fundamental shift in thinking about how services are developed and delivered. We're asking you to look at people, regardless of who they are and where they come from. The reforms proposed in Bill 173 are but a reorganization of the existing system of delivering services, and that's really scary. Our position is that we need to move away from an organization-based system to one which is individual-based and measured in terms of the people outcomes. We want people to be able to have lives, not programs.

I once asked someone the difference between life and a program, and this person said to me, "A program is limiting; life is limitless." Sometimes our programs really do cause people to have real limitations. So we are asking for a shift from specialized, segregated services to support systems in the community which recognize people and their uniqueness, because we all contribute in different ways. All of us sitting around this room contribute.


People with developmental disabilities should have access to all services in the community, whether it be the hospital or the library, and community services should be based on individual needs so that the supports are built around the person as opposed to a program that a person fits into. Because there's a spot in a program doesn't mean the person should fit it. So why do we take a peg and try to -- I don't know how you say that, but you try to ram it in something that it doesn't fit.

Mr Jackson: A square peg in a round hole.

Ms Easton: Well, thank you, Mr Jackson. I appreciate that. I would expect that from someone from Burlington.


Ms Easton: Well, I'm from Burlington. I grew up there. That's okay.

Mr Jim Wilson: His children have block sets.

Ms Easton: Oh, is that what it is? He's learned, has he? What can I say? I will now turn it over to Jim Mahaffy. Go for it, Jim.

Mr Jim Mahaffy: Thank you, Cheryl, and good afternoon. What I want to do is get right into the specifics of Bill 173 and try to underline a few of the points that underline what Cheryl was talking about in terms of a fundamental shift in terms of supporting individuals and not looking at programs as being the be all and end all.

To begin with, to address the legislation's proposed bill of rights, OACL supports the important, very new protections provided in the bill of rights for persons who receive services. The need for such a bill was outlined by Ernie Lightman in the report of the Commission of Inquiry into Unregulated Residential Accommodation, but unfortunately Bill 173 is silent on enforcement mechanisms other than litigation. For the people we represent and others, we feel the forthcoming regulations must provide for an easily recognized and accessible process for people to enforce this bill of rights.

I would like to next discuss our position on individualization. OACL generally supports the principles which have guided long-term care reforms. However, the association finds that Bill 173 is not sufficiently strong in recognizing the importance and the primacy of the individual. Specifically, OACL wishes to see part I, clause 1(c) include the principle of individualization, which "Asserts the basic human right of the person to have his or her unique capacities, interests and needs recognized and used as a basis for planning, developing and delivering such supports" -- as we're considering here in long-term care as well as others -- "as are required by an individual to live, learn, love, work and spend personal time."

In keeping with the principle of individualization and consistent with it, OACL advocates individual, consumer-directed funding, defined as: "A system in which funds for services are individualized (tied to the person).... The individual either manages the funds and engages support staff himself, or hires a manager to perform this function." OACL would like to see Bill 173 specifically provide for individual, consumer-directed funding.

Moving on to multiservice agencies, OACL feels that the government must address the issue of individualization, including consumer-directed funding, before proceeding with the development of the multiservice agencies. We feel very strongly that the government must establish principles and a process for reforming services to address individual needs before looking at mechanisms for pulling the various services together, looking at essentially what the needs of the services themselves are before tackling what we feel are the principles involved in addressing individual needs.

Having said that, we do support the establishment of coordinated access to a full range of long-term care services, but we do not support a service system which provides for only one choice of service provider.

Finally, on the subject of governance, if the government persists in developing the MSA model as currently outlined, OACL is concerned that the proposed legislation is not more specific with respect to the composition of the boards of district health councils and the proposed multiservice agencies. We feel that the act should set out a majority of consumer representatives on these boards. Furthermore, supports should be provided to ensure that consumers are effective representatives and not merely tokens in this process.

In fact, the Ontario Association for Community Living is concerned that the Ministry of Health, having the lead role through the district health councils in planning long-term care services, could impose or will impose its historical medical model on the newly developing system. OACL views the medical model as top-down, centralized and professionally driven.

Historically, we feel social service organizations have had stronger community representation than their medical counterparts and have made much greater uses of the resources of the community. This is in keeping with our philosophy in community living. We feel that the natural supports of the community must be considered in overall planning around individuals as well as paid services and supports.

In conclusion, long-term care, if it is to live up to its stated objectives, we feel must be collaboratively planned and implemented by all those affected by its outcomes.

Ms Carter: Thank you for your presentation. Certainly I have a great deal of sympathy for the point of view that you're coming from. I think that it is the consumers and the individuals concerned that have to be the focus of what we're doing, and I believe to a great extent that is happening, and I am certainly interested to hear from you the ways in which you feel we are meeting that ideal, if you like.

Interestingly enough, we had a presentation yesterday from Dr Michael Rachlis and Carol Kushner, who have written books on this sort of topic that you might know about. They reminded us of a system that exists in California called On Lok, where the money does in fact go with the individual rather than with the system.

I think a lot of us feel that this is a kind of goal that we should be approximating to, where the emphasis is on helping people to function rather than medicalizing them, as you have said. They did see what we're doing in Bill 173 as something that was at least beginning this process and which could evolve in that direction. They didn't see it as something that was cutting off those options. It may be that rather than reaching the ideal tomorrow, we do have to evolve, go through a process of getting existing agencies to come together and taking it on from there.

I certainly agree with you about consumer representation, genuine consumer representation, with power on boards as being essential. As you know, we do at least lay down in the act that 30% shall be such. So I'm just wondering whether you don't see flexibility in the system as it is being suggested and the possibility of evolving to the kind of thing that you want.

Mr Mahaffy: One of the main concerns we have that I mentioned perhaps very briefly is that it seems the government's intention is to designate the MSAs as being sole service providers. One of our central concepts in terms of individual planning is somewhat of a brokerage model, where people are able to go and access the supports they need in the community among people who may have varying types of abilities to be able to respond; for instance, a neighbour or someone like that who's able to provide support on a daily basis or a community agency where, say, a senior would want to contact someone who works for a community living association, or that kind of crossover. We don't see that this kind of flexibility is built into the legislation the way it is currently.

Ms Carter: I certainly agree with you that we want to have those possibilities of using what maybe is common sense as to what the ideal arrangement for a particular person might be, and I believe that's happened in other countries, that you maybe pay the neighbour to support a person or whatever.

But the way I see it, by bringing agencies together and centralizing the assessment of the person and the decision-making as to what they need, I think we're bringing in a lot more flexibility than we've got at the moment, where we have very discrete agencies with very definite mandates. Hopefully, when they're closer together there will be all kinds of permutations of service that will become possible.


We heard some time ago from Victoria County Community Care. They're not technically an MSA, but they are an amalgamation of existing agencies that has a lot of similarities with the multiservice agencies, and they certainly did feel that this gave them the possibility of being very flexible and being able to adapt to the needs of individuals because, as I say, we have a sort of pooling of all the possibilities, and because of that pooling it's much more possible to sort of pick and choose for an individual from the possibilities that are available. Of course, an individual's wishes are a very important part of what will finally be put together.

Mr Mahaffy: If I can comment, we certainly do support a single point of access into the service system, and we see that this is something that could dovetail very nicely with our approach of individual, person-centred planning. What we see is that person-centred planning is a very holistic approach, that someone's wellbeing and their level of functioning in the community is often built not just on the kinds of services that we might identify as long-term care services and that an approach that considered the holistic wellbeing of the individual could include access to a range of long-term care services but might also include other factors which would contribute to someone's wellbeing which weren't necessarily considered to be part of that package but might be very easily realizable through that person-centred planning process.

Ms Carter: I think that the local base of the MSAs, rather than having a bureaucratic structure, should make them more able to be flexible and to involve other parts of the community, if you like, in tailoring the services to an individual. I'm sure that is what we have in mind. I don't think there's any disagreement with you at all that that's what we should be doing ultimately. So I just hope that we can approximate that as fast as possible.

The Chair: Thank you. Any last thought or comment?

Ms Easton: I would just like to comment on that. I think there has been a lot of informal sharing of information and also trying not to categorize people by, "You're this" or, "You're that" or, "You carry this label" or, "You carry that label." I think that when you talk about your multiservice agencies it doesn't include churches or Lions clubs or any of those sort of things that provide a lot of informal support. I think if we get into really hard-core stuff, we're going to miss the boat on a lot of things that are done by a community that are just good things, just because they live next door or they're a part of the community and they belong to the Knights of Columbus or whatever it is. So I'd worry about that a little bit with the one-stop shopping, because whenever you one-stop shop, a lot of times when you get into multiservice agencies, they trade you about.

Ms Carter: As I said, they will all be locally based, and hopefully they will have links with the Lions Club and all those other things and they'll be able to use their help.

Ms Easton: Well, I hope so.

The Chair: Thank you. I'm afraid we're going to have to close it there, but I think many of us around this table know of the excellent work of the OACL, and it's good to see you all again.

Ms Easton: You always will see us, fortunately or unfortunately.

The Chair: I know that, Cheryl.

Ms Easton: Did you allow Jim to say his last thing?

The Chair: Oh, sorry.

Mr Mahaffy: I just wanted to say that, like the previous presenters, we would also like to see some input into consultation around the regulations for Bill 120 as well.


The Chair: I call the representatives from the Learning Disabilities Association of Ontario. We want to welcome you to the committee. I have to say, Eva, to you that you have gone from one position to another, but it's got a lot more words next to it. I don't know whether that makes you more powerful and authoritative.

Ms Eva Nichols: Not at all.

The Chair: Just the same warm person. Okay.

Ms Nichols: I'm just a consultant today.

The Chair: Well, we want to thank you for coming to the committee today. If you introduce yourselves, we have a copy of your presentation and please go ahead.

Ms Nichols: My name is Eva Nichols, and I am now called a consultant in advocacy legislation and government liaison, which is indeed a lot more words, but it also spells out very clearly what my revised role is with the Learning Disabilities Association.

Immediately to my left is Sharon Bell-Wilson, now the executive director of the Learning Disabilities Association, and next to her is Tanya Lewis, assistant executive director and program director.

We are going to start out with me making some introductory comments, not very long because you have our written material in front of you, and then hopefully you will have some questions for us which we will all three respond to as it seems appropriate.

First of all, we would like to thank the committee for arranging these additional days for the consultation. I'm sure you've found that there has been a lot of interest in the issue of long-term care, perhaps more than you had originally anticipated, and I think that may be in part because the mandate of what came under long-term care seems to have expanded significantly since when it was first announced in 1991 and people were talking about services to seniors and to people with physical disabilities. That is at least what the minister announced at that time. The additional things that seem to have come in under the multiservice agency model I think have meant that a lot more people have become a lot more interested, and a lot more concerned in some cases.

I would imagine that many of the people who have come in front of you have talked about the details and the minutiae of what is included in the bill. As is so often the case for people who represent people with learning disabilities, our fundamental first comment to you always is that we are still concerned about equity issues and the whole question of people with learning disabilities being included.

If we were engaging in a one-to-one dialogue, you may say to me, "Well, where is there in Bill 173 that people with learning disabilities are not included?" and I would certainly agree that that is not so. Nevertheless, all the discussion, all the dialogue that has gone on with some of the staff of the Ministry of Health, for example, has indicated that the school health support services, speech and language pathology services, social work services that will be included in the mandate of these multiservice agencies will not include services to people with learning disabilities. So our first and most important concern to place in front of you is, please would you ensure that the kind of discrimination that people with learning disabilities face doesn't continue in their being excluded once again in this area.

I think the other point we would like to put in front of you is that we have some concerns about the whole business of communication as to how all of this is going to develop. It seems to me that involving people like school boards and the organizations that are particularly concerned about school health support services has not appeared to have occurred as effectively as it might.

For example, the Ministry of Health was going to circulate to all school boards and all agencies concerned with school health support services a revised manual for the delivery of school health support services in time so that you, as a committee looking at this bill, could look at what all those organizations really believe about that. I know for a fact, because I checked yesterday, that those manuals have not yet been sent out for consultation to the school boards and to the other organizations that are to provide input. It would be a tremendous problem, I think, for this province and for the people this bill is supposed to protect from all kinds of terrible things if in fact that consultation occurred after you had done your clause-by-clause review, there had been third reading and somebody would say, "Excuse me, but have you considered all these various things?"

I obviously don't know who has been in front of you, maybe you have seen all 180 school boards here commenting on that particular issue, but I think it's an example of the lack of communication that appears to be out there. While people fundamentally support the deinstitutionalization thrusts of this bill and its one-stop shopping thrust, we want to be very, very sure that when it is finally proclaimed, whenever that occurs, it truly reflects the needs of all those people who need to use long-term care services and in particular that it includes people with learning disabilities who need those services.


Mrs Sullivan: I appreciate this brief very much because I am deeply concerned about the integration of children's services into the multiservice agency. I think that there has been little planning and that the original concept in fact did not include children. The thinking was that children's services would be dealt with in another manner, and perhaps that's the most appropriate way to go. In fact, that's certainly my leaning.

I raised yesterday in committee the question of children and how they will be included in the bill, and unfortunately we have not had time for a full briefing for the committee from the ministry with respect to the intentions about children, but it seems to me that when home care is now mandated to provide school-based health support services, when home care also provides much of the service that's provided in-home or in the community base and establishes contracts with treatment centres and so on, given that home care is going to be integrated into MSAs, there is no option other than that children's services are going to be included here.

I look at the list of required services, the mandated services, and I think having mandated services across the province so that there is a basic basket is appropriate. But why, for instance, are only adult day programs included when day programs for children, particularly at the preschool age, may well be an important part of the service delivery?

I did not know what you have pointed out in your brief, that in Metro, and I'm just quoting from the brief, "...it has been stated that while school-based health support services are a part of the process in principle, services for children will not be included in their proposed multiservice agency plan until the review of services offered through the Hugh Macmillan and Bloorview centres for children with physical disabilities is complete."

You go on to speak about speech and language pathology. I'm concerned that, for instance, while speech and language pathology is included as a mandatory service under professional services, for the elderly, frequently the work that's done by the speech and language pathologist relates to swallowing and is a very different kind of service from what is provided by the paediatric speech and language pathologist.

I'm going to ask if the ministry and the parliamentary assistant can respond at least briefly now on the intention of the minister with respect to children, if it's the intention that children's services would be included in a regional MSA that would -- the Metro situation is going to be extraordinarily difficult with 17 MSAs, or 22 or however many they end up with, none of them with a particular emphasis on children, whether those specialized services would be included or whether the ministry has considered limiting this bill, as it limited Bill 101, to seniors and people over the age of 16 with disabilities.

Mr Wessenger: I somewhat anticipated that would be your question, Ms Sullivan, so I'm going to ask Mr Quirt to respond. I think we should be clear that children are part of the MSA structure, but how they're going to deal with it I'll ask Mr Quirt to indicate.

Mr Quirt: First of all, they've always been a part of the long-term care client group and a part of the long-term care redirection, going back to the mid-1980s. Ever since the home care program has been involved in providing services to children, whether in school or at home, they've been an important client group that needs to be served. There was never at any time a contemplation that they wouldn't be subject to the improvements in the long-term care system, and as a result there is no intention whatsoever to reduce the amount of support provided the children at home or in school through the school health support services program.

With respect to children's treatment centres, which has been raised yesterday as an issue and again today, children's treatment centres will continue to be funded from three places: They get funding from the Ministry of Education and Training now for some of the services they provide. They get core funding from my division for another group of services they provide. Third, when home care programs or the MSAs are going about fulfilling their mandate to deliver the school health support services program, they need to arrange for the provision largely of therapies to kids in school, whether it's PT or OT or speech therapy or whatever. If a kid needs those services, we'll deliver it, whether they have the additional label of being learning-impaired or not. If they need those services, they're one of our clients.

In those cases where there's a CTC around, some home care programs say, "If we have to buy this, why don't we buy it from an agency that has some experience and a history of dealing with children?" If there isn't a CTC around, the home care program buys those therapies or nursing from any of the other providers, a hospital or the VON or whoever is around to deliver those services. That will continue, and we expect that in many communities the 20% purchasing limit afforded multiservice agencies will be used in those circumstances where a unique or particular perspective or set of experiences or a particular affinity for children might be able to be purchased from an organization such as a CTC. So their funding is secure, to say the least, and the school health support services program will continue to be an important part of the long-term care system.

Mrs Sullivan: I'm still not reassured, in that if the 20% limit is exceeded and there is still a demand for services beyond that, there is a huge problem and the only out of that problem is to move to an individual. I understand that CTCs don't exist in every part of Ontario, but it is a big problem. I don't think the ministry has addressed it.

Mr Quirt: You're quite right that this would pose a problem, particularly in the Metro Toronto circumstance, the example that you used. My understanding of the planning at the district health council level is one that expects that some of the 15 to 20 multiservice agencies in the Metro area will indeed have a specialization.

Perhaps one MSA may have a specialization in dealing with a particular ethnic group and providing services in a culturally sensitive way to that group. Another MSA may well attract those professionals in the system who have a particular ability to relate well with children and to deliver the school health support service program well. For that reason, any purchase from one MSA to the other, whether it's to buy services for children or to buy services for a particular ethnic client group, is excluded from the 20% rule.

In addition to that, they could buy an array of services from an MSA down the road or across town and that wouldn't affect their 20% purchase limit at all. On top of that, they could contract for the services of an individual if it was a highly specialized service and that individual service purchase wouldn't count towards their 20% either.

Ms Nichols: I would like to comment that all of that sounds very good, but the bottom line still is that the Metro Toronto district health council, at its series of meetings, reiterated over and over again that it was not allocating anything for children, that it was not setting up a specialized MSA for children, and it still doesn't alter the question I raised about the whole business of consulting people who are currently delivering school-based health support services. It's a good idea to consult them, but it would be better if they were consulted before things were a fait accompli at the Legislature level.

Mr Quirt: Just to make sure that people don't get the impression that services won't be continued to children, it's my understanding that the DHC is awaiting the review of services at Bloorview and at Hugh MacMillan, and quite frankly, if the DHC recommends a proposal that doesn't adequately serve children, it won't get approved. We expect they're interested in the results of those two studies so they can recommend to the minister the appropriate way to optimize the use of resources for children in Toronto. There's no way in the world we're going to approve a bunch of MSAs in Toronto without the school health support service program being provided in an effective and complete way.


Ms Nichols: If I may just ask a supplementary to that, the ministry staff who have attended such things as the special education advisory council at the Ministry of Education and Training have said that children with learning disabilities who currently can have speech-language pathology services under home care will not likely get those services because of the limitation of services to children. What can we look for in terms of services for those children?

Mr Quirt: You can look for exactly the same level of support for children under the MSA system as they get now under the home care program. There's absolutely no way in which we're intending to diminish the eligibility limitations that are currently in existence for the school health support service program. On the contrary, we hope that the establishment of multiservice agencies and the capacity to have a range of services internal to the agency rather than relying on the brokerage model will allow people to do a better job in meeting those needs.

As I said earlier, our clients in the school health support service program are eligible for our long-term care services, the therapies that are listed in the document. That's what they get now and that's what they'll continue to get if they remain eligible. There's no intention to reduce service to kids as a result of this. The idea is to make services to children better.

Ms Nichols: Perhaps if there's another question --

The Chair: There is a Hansard record there that I think --

Ms Nichols: No, no, I fully understand how to use that information.

The Chair: -- as they say, is evidence you may take down and use. I regret that with all of the presenters, we have to limit it to one questioner, so I'm afraid our time is up. But I do want to thank you, as always, for coming before the committee, and I suspect you will be before similar committees in the future as well.

Ms Nichols: Absolutely. Thank you very much.


The Chair: I call on the representatives from the Ontario Association for Volunteer Administration, the Ontario Association of Directors of Volunteer Services in Healthcare and Volunteer Ontario, the Ontario Association of Volunteer Bureaux/Centres. I almost want to say that you are all here voluntarily, but I won't say it. Welcome to the committee. We have a number of documents in addition to your brief, so if you would just be good enough to introduce yourselves, and then please go ahead.

Ms Lorraine Street: My name is Lorraine Street. I'm the executive director of Volunteer Ontario, the Ontario Association of Volunteer Bureaux/Centres.

Ms Carol Dixon: I'm Carol Dixon and I'm president of the Ontario Association of Directors of Volunteer Services in Healthcare.

Ms Lynn Ziraldo: I'm Lynn Ziraldo, president of the Ontario Association for Volunteer Administration.

Ms Street: By way of preface to this brief, I would like to say that we recognize that the language in it is quite strong. Unfortunately, we can't apologize for it. We believe at this point that the language in relation to this discussion has to be strong. We have some very significant concerns, particularly about the role of volunteers in long-term care.

We appreciate the opportunity to present our views before this committee today. Our intention is to raise with you our concerns with respect to voluntarism and the changes to the long-term care system proposed in the bill under discussion.

Our organizations have been offering comments on the proposals to reform the long-term care system since discussions began more than six years ago. When the Redirection of Long-Term Care and Support Services in Ontario was first released in 1990, Volunteer Ontario and the Volunteer Centre of Metropolitan Toronto presented a brief to the senior citizens' alliance hearings. It included the following points, which all three of our organizations now present again as basic issues which must be addressed carefully and completely in the articulation of the newly reformed long-term care system.

(1) While acknowledging that volunteers play a significant role in the delivery of long-term care and implying that the role will be expanded and enhanced in the reformed system, the Redirection of Long-Term Care and Support Services in Ontario and subsequent policy documents do not address the issues attendant upon that involvement. This must happen, we believe, before the system is reformed.

(2) If volunteers are to continue to play an important role in long-term care, adequate resources, both human and financial, must be included in the core operating budgets of agencies and programs. Such resources will be used in the recruitment, proper placement, orientation, training, recognition and ongoing support of volunteers, all of which should be managed by competent, professional paid staff.

(3) The proposed reforms will have a significant impact on the role and function of volunteers, care givers who are informal volunteers and formal volunteers who work for agencies or organizations providing services. Professionals in the management of volunteers and volunteer programs, including representatives of volunteer centres, managers of volunteers and volunteers themselves, must be given a place at the planning table in order that programs are properly organized with respect to these issues.

(4) There is general confusion and/or disagreement about the appropriate roles of volunteers and paid staff within the reformed system. This issue must be addressed explicitly and as soon as possible in order to avoid potential conflicts between volunteers and paid staff.

The Ministry of Health is currently moving to address some of these issues, in particular through the establishment of a provincial advisory committee on the role of volunteers in long-term care, on which our organizations are represented. Nevertheless, we believe there are other overarching concerns which are not being addressed and on which Bill 173 is largely silent.

We understand that the bill sets out the legislative and policy framework for the new system and does not purport nor intend to provide the detailed structure for it. The concerns we are raising are, we believe, important matters of policy, as opposed to matters of structure or service delivery, and as such should not -- should be treated in the bill and not left to the regulations.

The Chair: Just to be clear --

Ms Street: Just to be clear, there is a "not" there that shouldn't be there: "and as such should be treated in the bill and not left to the regulations."

The first is the nature and role of voluntary action in long-term care services, and I quote from two of the long-term care documents: "Up to 90% of all assistance to seniors and people with disabilities comes from family and friends and not from formal programs" and "Volunteers are the lifeblood of long-term care."

The documents just cited confirm that the place of volunteers and voluntary action in long-term care is enormous indeed. We are therefore puzzled to note that there is one paragraph in Bill 173 which focuses on volunteers and that this paragraph does not establish a legislative or policy framework for the involvement of volunteers in the reformed system. Rather, it provides for the Lieutenant Governor in Council to make regulations "requiring multiservice agencies to develop and implement a plan for recruiting and using the services of volunteers."

We have long urged the provincial government to develop and articulate a policy on volunteerism and would argue that the advent of long-term care reform, whose very lifeblood is volunteers, makes the delineation of such a position imperative and urgent.

The promotion of volunteerism is obviously not the goal of long-term care reform. Nevertheless, this huge endeavour illuminates the lack of consensus in our community about the role of volunteers, perpetuates many of the myths that continue to surround volunteerism, and in particular seems to take for granted the continued participation of volunteers. While we are certain it is unintentional, the documents relating to the reform of long-term care in Ontario seem almost to treat volunteers as warm bodies that can be moved around on a board to suit the needs of the system.

Long-term care reform is built on the notion of the dignity and autonomy of individuals. Indeed, it makes the rights of clients paramount. It also seeks to protect, as it should, the jobs of paid staff who may be displaced in the reformed system. It says nothing, however, about the rights and dignity of volunteers, nor does it make any mention of the fact that the system is built on their work.

Important status is accorded service providers in the bill; important status and protections are promised to homemakers and care givers. However, no such status and no such protections are promised to the volunteers who provide so much of the services. Nowhere in the bill are the rights and responsibilities of volunteers as primary care givers, informal and formal volunteers, spelled out. Bill 173 guarantees immunity from liability to directors and program supervisors but makes no mention of immunity from liability for volunteers, who provide so much of the care.

The question thus forces itself upon us: Why are volunteers seen as so crucial to the reformed long-term care system, yet virtually ignored in the legislation which creates it? If we look at the Advocacy Act in contrast, it is clear in the reports and studies which underlie it, in particular the O'Sullivan report, the Review of Advocacy for Vulnerable Adults, that volunteers are sought to participate in this new system because they bring something that is different, extra, special to the care of human beings. Is this same notion fundamental to the reform of long-term care? If it is, then why is this notion not built into the principles which have been enunciated to guide the unfolding of the new system, and why is it absent from the legislative policy framework?

This seemingly paradoxical treatment of volunteers is typical of the ambivalence of society towards them and their work. On the one hand, they are almost canonized, often to the denigration of paid staff. On the other hand, they are treated as amateurs, viz the often used contrast of "volunteer" and "professional" instead of "volunteer" and "employee" or "paid staff member" and are not included in planning and development, seen as expendable, or, worse, as simply a cheap means to an end.


The great fear of course is that volunteers are seen as indispensable to the reformed long-term care system basically because they are not paid salaries, and therefore a system whose very lifeblood they provide will be, by definition, a cheaper system. Is this voluntary action as providing something essential and different, or is this voluntary action as the tail end of the welfare state, with volunteers filling gaps and being used because "There isn't money to pay people to do everything"?

Our second issue: Who will do what in the reformed system? Here, we and many other professionals in volunteerism would raise questions that parallel those asked here yesterday by Julie Davis of the Ontario Federation of Labour. What are to be the roles of volunteers and the roles of paid staff in the new system? Who will decide what they should be, and according to what criteria? Is it adequate, appropriate or right that these issues should be decided at the local level? Should they not issue from a comprehensive provincial policy worked out with the complete participation of professionals in the field -- that is, in particular, volunteer centres and managers of volunteers -- with volunteers, and with labour?

We can say categorically and from direct experience that volunteer/paid staff tensions and hostilities have already begun to surface. This situation will not improve without serious discussion, which we believe should take place at the provincial level.

Again, we recognize that the bill does not set out to detail the workings of the system. We argue that the issue, really the web of issues, surrounding the question of who will do what work is a policy issue and not an issue that should be left to the regulations or to the decision-making of individual communities.

The core of our concern is that, whatever the original intentions and underlying principles about the importance of the participation of volunteers per se, the fear is that in these difficult economic times, what will drive decision-making about who does what will be questions of dollars and not questions about who should be doing what or who is best to do what. The fear is that volunteers will become, crudely put, cheap labour. This is both an insult to volunteers and a legitimate concern to labour. This is not just an issue of where volunteers might replace paid staff; it is also an issue of where paid staff might replace volunteers.

What is the real position of volunteers in long-term care vis-à-vis that of paid staff? Are they interchangeable? Are their roles to be determined by rigid rules? Will there be a new hierarchy of positions, with volunteers at the bottom?

A third concern is that of support for volunteer programs. The concern is that established agencies and organizations whose role it is to promote, educate and train etc -- that is, volunteer centres, managers of volunteers, associations for volunteer administration -- are being bypassed in this reform. We believe they should have a recognized and distinct role in the development of this system which will be based on volunteer services, as this is the field of expertise of these agencies.

In conclusion, we recommend that the government use this opportunity to develop and articulate a policy on volunteerism which then can be built into Bill 173 and other legislation and initiatives. We recommend that the government convene a task force including volunteers, labour representatives and professionals in the field of volunteerism from volunteer centres and from the ranks of managers of volunteers to assist it in the development of such a policy. We recommend that the community resources now available, including volunteer centres and managers of volunteers, be respected and supported, and not supplanted in this new system.

Mr O'Connor: Thank you for your presentation. We've heard a lot about volunteers as we've gone through this, and there isn't a member of Parliament, I don't think, in the Ontario Legislature that doesn't know how important the role of volunteers is in each of our constituencies. It doesn't matter what group you go to, there's always a corps of volunteers that is behind it.

One of the suggestions made to us was in part VI of the bill, where there is the discussion around the board composition of the MSA. Someone had made a suggestion -- and I'm going to forget who it was so I'm not even going to attempt to try to remember, but they suggested that maybe in the composition of the board, that portion of the bill would be a proper place that maybe we should place some recognition of the volunteers and the role they are going to play, because they will play an important role. I just wondered if you had any thought to that.

One other portion was in the regulation part. It was mentioned to us I guess by one of the Ontario associations that in the services for volunteers, training should be included in there, trying to work on retention so that, you know, by giving them the training you're going to then recognize that you'll keep the volunteers in place, and some recognition and perhaps even some expense reimbursement if necessary, that maybe that should be included as well in the legislation. I'd just like you to comment on that if you would, please.

Ms Ziraldo: I'll comment on one aspect. As far as the management of volunteer resources, one of the attachments you got was the standards of practice that our organization has developed that has been approved by the 300 or so agencies that are involved. So I think that will be very helpful if you definitely include something in the bill, as I would strongly recommend, because there's no way that you can have the volunteers that you're going to have involved with long-term care if you do not have someone managing them etc. So I definitely would stress that you look at this material very carefully.

Ms Street: It is standard practice in the field to include resources for proper orientation, supervision, training, screening, recognition, evaluation etc. That is standard practice and should be included.

I'm sorry. I didn't understand the first part of your question, about the boards.

Mr O'Connor: Okay. Part VI of the bill describes the MSA. It describes what the composition should be made up of. There's been a policy decision made by the government that it be one third consumer. Some people are saying it should be higher. But it's been placed before this committee that in that portion of the legislation, we should place in there a role for the volunteer in the board -- of course, the board will be all volunteers, but something in there that would reflect that the board is volunteers.

I don't know whether you had something you wanted to put in there, because what you'd suggested was that the only time it mentions volunteers is when you go into the regulation part where it talks about the role of the volunteer. It was suggested that maybe in the composition of the board we should recognize the importance of the volunteer. I just wondered if you had something you wanted to add to that section that would recognize their importance.

Ms Street: I guess in reading it, the assumption is that in a non-profit corporation the board would be made up of volunteers. It certainly couldn't hurt to add the word explicitly.

Mr O'Connor: The other one in the regulation portion was by the Ontario Community Support Association. They on several occasions have come before us and made that recommendation around volunteers in the regulation portion. Maybe if we can make that suggestion available to you, you can take a look at it and get back later on.

Ms Street: Certainly.

Mr Martin: Part of the discussion we've had here over the last few weeks re this thing is the question of, why do people volunteer and will we be able to transfer the large number of volunteers who are out there now in the various organizations who are seeing their role diminish to this MSA? I'd just like to hear your comments on that.

Ms Dixon: I'm director of volunteer services for the Mississauga Hospital and I know that a great many of the people who come and volunteer at the hospital to work with health care kinds of clients would not be inclined to leave the safety of our big building, knowing that there's always staff there, to go out to people's homes and provide these kinds of services, because there are concerns of the kinds of risks that are there. We have this when we do cross-training with things like Hospice of Peel, and we find that the volunteers who are trained even for them to go into clients' homes sometimes feel more safe in the hospital. So I would say that a lot of our volunteers would not make the crossover.

They're also very familiar with where they're working and what they're doing, and there is certainly a social component to part of why the people are coming to volunteer at the hospital. You'd have to try and take that whole group of things with you when you go.

I didn't explain that very well, but there's a lot more to it than just hiring somebody.

The Chair: Did anyone else want to comment on that?

Ms Ziraldo: I think my only comment would be the issue that if you're transferring the volunteers etc, how you manage and coordinate that and how you train them will be crucial if they're going to be effective for the consumer, or the client. I think our concern is that as you're transferring them, if that happens, how that training will be done will be crucial. They might be used to specific training on the area of hospice or whatever, and then all of a sudden you're going to put it in one group. Who's going to train them? What kind of training does that person have who's training them? Who's going to coordinate them? Who's going to ensure they're retained? That's where I think most of us would be coming from.

Mrs Sullivan: A special mission of the organization.

Ms Ziraldo: That's right. They're committed to a certain mission, to a certain belief, and to have it a global, who's going to get lost in that shuffle? I have a feeling that not only will it be the volunteers, but it will also be the consumer and the clients.

The Chair: Thank you very much. I think as you know, this has been an issue that has come up --

Ms Ziraldo: Several times.

The Chair: -- different times, but we appreciate the three of you representing a number of volunteer organizations and the various background documents you've left with us. Thank you very much.



Le Président : J'aimerais maintenant inviter M. Omer Deslauriers pour la Coalition de planification de l'OSP francophone du grand Toronto. Monsieur Deslauriers, vous êtes bienvenu, et vous n'êtes pas seul ; il y a quelqu'un d'autre qui va vous rejoindre à la table. Alors, peut-être que vous pourriez vous présenter aux députés.

M. Omer Deslauriers : D'accord. Je vais parler assez lentement pour donner une chance aux autres. Je suis très heureux d'être ici aujourd'hui.

Le Président : Les députés sont en pleine forme, alors il n'y a pas de problème.

M. Deslauriers : Il y a Mme Lebeuf, qui est secrétaire générale de RIFSSSO. C'est un organisme dont je vais parler qui est en charge de réunir les professionnels de la santé ou des services sociaux qui travaillent pour des vieillards.

La présentation portera sur un point seulement : l'inclusion dans la loi d'un paragraphe qui voudrait que le Ministre parle un peu de la Loi sur les services en français.

Mais, en général, on peut dire que nous sommes des consommateurs. Nous sommes en faveur du projet de loi 173 et nous sommes très heureux de voir que la plupart des journaux, la plupart des rapports qui ont eu lieu dans votre voyage à travers la province laissent entendre que le projet de loi 173 sera accepté. Donc, les consommateurs sont en faveur.

Ceux qui donnent des services : Il y a 15 ans, on n'avait pas de personnes francophones, tellement, qui donnaient des services aux personnes âgées. Il n'y avait pas d'ergothérapeutes, de physiothérapeutes, d'audiologistes, tous ceux-là. Là maintenant, à l'Université d'Ottawa, il y a un service en français pour former ces gens-là.

Hier, vous avez assisté, je pense, par voie des journaux, à l'ouverture d'un collège francophone même dans le sud de l'Ontario, le Collège des Grands Lacs, qui va nous aider à former des gens pour donner des services aux vieillards, parce que, actuellement, on n'a presque pas de services pour les personnes âgées. On vient d'ouvrir une maison pour les vieux à Scarborough mais il faut aussi voir l'esprit francophone.

La Coalition voudrait vous présenter un paragraphe dans le projet de loi parce que nous trouvons que la réforme des soins de longue durée est une réforme très importante car ça regarde à peu près toutes les personnes de l'Ontario. Par cette loi, le gouvernement cherche à résoudre le fait que les gens doivent passer par tout un dédale pour obtenir et avoir des services. À ce moment-ci, on veut que, par un coup de téléphone, on puisse avoir accès à ces services-là.

Le nouveau service doit être axé sur l'usager. Autrement dit, il doit être d'un accès plus facile, encourager le mieux-être, répondre aux besoins des francophones, d'après la Loi sur les services en français, et des groupes ethnoculturels.

Le CRSTM, Conseil régional de santé du Toronto métropolitain, est très conscient de la présence de la communauté francophone dans la communauté urbaine de Toronto et a considéré, dans ses différents comités, la planification en incluant les services en français.

Le Conseil recommande la création d'un cadre pour les organismes de services polyvalents à l'échelle de la communauté urbaine de Toronto. On veut 15 OSP et on en voudrait aussi un francophone.

Donc, il est à noter que le Conseil a inclus dans sa demande au Ministre un OSP mandaté pour dispenser des services en français à tous les francophones dans la communauté urbaine de Toronto. Nous voulons même aller à Peel, à Durham, parce qu'on voudrait avoir un endroit où il y a à peu près 100 000 francophones, dans ces régions-là. On ne croit pas que la population de Peel, York et Durham soit assez nombreuse pour donner des services en français ; on pourrait les inclure dans notre OSP de Toronto.

Répondant à la recommandation du CRSTM, un groupe de francophones se réunit régulièrement depuis le mois de juillet pour établir un consortium pour mettre sur pied un organisme de services polyvalents tel que recommandé par le Conseil régional de santé du Toronto métropolitain. Ce groupe a étudié le projet de loi 173 et vous recommande d'amender ce projet de loi avec le paragraphe complémentaire pour conserver un principe d'équité, et d'y inclure l'obligation aux conseils régionaux de santé de planifier les services en français dans les régions désignées par la Loi sur les services en français.

On voudrait, s'il y a moyen, que vous utilisiez la possibilité d'inclure dans le paragraphe 62(1) du projet de loi, juste avant le paragraphe sur les Indiens :

«Lorsque les services de santé d'une région désignée par la Loi sur les services en français est du ressort d'un conseil régional de santé, le Ministre peut enjoindre ce conseil régional de santé de collaborer à sa planification avec la communauté francophone pour assurer les services en français.»

Donc, si on aurait ces services à Sudbury, si on en aurait à North Bay et on en aurait dans le nord de l'Ontario, dans tous les endroits où la Loi sur les services en français existe, le conseil régional de santé pourrait, avec les francophones, discuter de la mise sur pied d'un OSP francophone.

De plus, il est important que la loi soit consistante en français. Le reste n'est pas tellement important. On voit dans la traduction que des fois on parle de «pensionnaire», des fois on parle de «résident». On voudrait, quand en anglais c'est toujours «resident, resident, resident», que ce soit «résident» et non «pensionnaire» ou «résident». C'est mélangé en français.

C'est à peu près tout ce qu'on a à demander. Au fond, ce qui est important pour nous, c'est que votre groupe de parlementaires inclue le paragraphe dans le projet de loi 173 pour qu'on mentionne un petit peu l'effet de la Loi 8, et que dans ces endroits-là où les régions sont désignées, le conseil régional de santé doit rencontrer les francophones pour discuter des services en français, parce qu'on a un problème. On ne l'avait pas il y a 20 ans, 25 ans. Les francophones, comme peut-être les anglophones, s'occupaient de leurs personnes âgées. Là maintenant, les gens travaillent : le père travaille, la mère travaille. Les personnes âgées sont laissées seules à la maison. Il n'y a personne pour s'en occuper. Maintenant, il faut s'en occuper et ça va vider les hôpitaux.

Vous connaissez tous les avantages du projet de loi 173, et je pense que si le projet de loi 173 va bien, s'il est bien fait, on va réellement assister en Ontario à toute une promotion des services pour les personnes âgées, et puis d'un autre côté on pourra aussi s'en servir comme francophone.

Donc, je vous remercie beaucoup de l'attention que vous m'avez donnée. Je suis prêt maintenant à répondre à quelques-unes de vos questions.

Le Président : Merci beaucoup pour la présentation. On passe à M. Wilson.

M. Jim Wilson : Merci pour votre présentation. That's the extent of my ability in the French language today. You raise a very good point that's been raised before in terms of the need for a francophone district health council serving Metropolitan Toronto and beyond. You mention that there are at least 100,000 to 175,000 francophones.

Mr Deslauriers: We're about 60,000 in greater Toronto, but I think no service will be done in French in Peel or Durham. There are not enough, but with us, it would be enough.

Mr Jim Wilson: The way the bill is structured, I really don't know. I don't see that it's possible to have a specific MSA designated. But I do want to give the parliamentary assistant to the Minister of Health the opportunity to respond to this, whether or not it is possible in this legislation. Secondly, what is the intention of the government with respect to serving francophone members of our communities?

Mr Wessenger: First of all, when the minister approved the Metro DHC planning framework, she highlighted the need to plan for the ethnocultural communities. Her letter was also supportive of the DHC recommendation that there be a Metro francophone MSA, and that's with respect to Metro.


With respect to the areas outside Metro, a letter has gone out from the minister and the minister responsible for francophone affairs to the DHCs outlining the need for the DHCs to plan for francophone services where they're required under the French Language Services Act. I just point out that in the restructuring of long-term care, this legislation does provide that the services be culturally and linguistically appropriate, so we see this as quite an advance in this area.

Mr Jim Wilson: You've seen that assurance from the minister, have you?

Mr Deslauriers: For greater Toronto?

Mr Jim Wilson: Yes.

Mr Deslauriers: No, not yet.

Mr Jim Wilson: Was this assurance provided in the form of a letter, did I hear you say?

Mr Wessenger: I don't have a copy of the letter with me, but I understand there was a letter sent out.

Mr Jim Wilson: A commitment made to ensure there would be a francophone MSA --

Mr Wessenger: No, it was a letter that was supportive -- I understand there was a DHC recommendation that there be a Metro francophone MSA, and the minister indicated her support.

Mrs Sullivan: A francophone representative on the --

Mr Wessenger: No.

Mrs Sullivan: One MSA?

Mr Wessenger: One MSA that would be francophone, yes.

The Chair: I'm sorry, just so we're clear, there was a letter from the minister --

Mr Wessenger: That indicated her support of that recommendation.

Mr Jim Wilson: And what you're requesting the committee today is that there actually be an amendment added to ensure that's the case?

Mr Deslauriers: No, if the minister wants to make it for Toronto it's okay for us. We were speaking also for Sudbury, for North Bay, for Kapuskasing and for other places where there are French-language services, I think sections 23, 24, throughout the province.

Mr Jim Wilson: I would think that the French Language Services Act is paramount, certainly not overridden by this legislation. So in areas where francophone services are currently deemed to be provided, I would think they also have to be respected in the health care field. Perhaps legal counsel could just clarify that for us.

Mr Wessenger: Legal counsel can clarify that, but I believe you're quite right, Mr Wilson.

Ms Czukar: Yes, the French Language Services Act is the legislative framework in Ontario for ensuring that services are provided in the French language in those areas that are designated under the act, and the minister has made the commitment that they will be provided in the designated areas.

Mr Deslauriers: We want it included in this bill because DHCs are not always aware there's a bill for French-language services and we have to go all over the legislation to explain to people in the DHCs --

Mr Jim Wilson: So they're not always --

Mr Deslauriers: A small thing in the act that would refer to the French Language Services Act to have services in the French language.

Mr Jim Wilson: You are recommending an addition to section 62?

Mr Deslauriers: 62, subsection 8.1(5).

Mr Jim Wilson: Could legal counsel comment on the proposed amendment?

Ms Czukar: I believe that's in the district health council section. I'm not sure what the proposed amendment would be exactly, but district health councils have been requested by the joint letter from our minister and the minister responsible for francophone affairs that they consider the French-language service needs of their communities from the outset in planning MSAs so that when it comes time to have a francophone MSA or an MSA designated under the French Language Services regulations to provide the services in the French language, then they will be prepared for that.

Mr Deslauriers: That's what we're asking for. But if it's not in the law, it's a lot more difficult. When we refer to other legislation, it's difficult for them to put it in effect.

Mrs Sullivan: Could I just ask a question, Mr Chairman, as a supplementary?

The Chair: Point of clarification, Mrs Sullivan?

Mrs Sullivan: Yes, it really is. I think that one of the things that's a matter of concern -- I suppose Metro Toronto is an issue and I don't know what Sudbury has planned, by example, as to whether there's going to be one MSA for the entire region -- but an MSA implies a duplication of services for a separate MSA. I'm wondering if your organization would consider that a satellite of the MSA that has the francophone capacity for service delivery would also be an appropriate vehicle if a DHC chose that approach, rather than a separate MSA for a region.

Mr Deslauriers: I would accept this, depending on the number of people who live there. If we are 60,000 -- some say we are 175,000 in Toronto. I would not vouch for 175,000, but if certain decisions have been made, if we have the numbers, we would like an MSA. If we are not numerous enough we would accept a satellite of it, but as numerous as we are, we think we deserve, and the DHC has approved, an MSA. But in certain places, for example in Thunder Bay, there are not enough. They say, "Come on, you cannot have a French MSA," so other means have to be found to deliver services to the French people.

Mr Jim Wilson: In Metro Toronto, because there are large numbers of francophones, you really do need your own MSA in terms of needing that initial contact in the French language and the understanding and culture that go with that.

The way I envision this, and maybe the parliamentary assistant wants to comment, since MSAs can contract with each other for services, could you not set up an umbrella francophone MSA that would provide as much as it could provide of the basket of services in the French language? And then, because contracting with other MSAs is not affected by the 80-20 rule, you could have other services provided by the local geographical MSAs.

Mr Deslauriers: What was proposed by the Toronto DHC was 15 geographical MSAs. You're aware of that: three for Scarborough, four for Toronto, but the French one would cover the whole of Metro Toronto.

Mr Jim Wilson: I'm just trying to fish out what that might actually entail.

Mr Deslauriers: But they may contract with one MSA for services.

Mr Jim Wilson: Right, okay. So we're thinking along the same lines. Is that the thinking of the government?

Mr Wessenger: Yes, that certainly is the thinking, that for instance a francophone MSA in Metro Toronto could obviously provide services to another MSA in an adjoining area. Also, it should be remembered that in each area where there is, subject to the French Language Services Act, an obligation to provide the services, an MSA would be designated to provide those services in each of those areas. So there would be a designation for an MSA to provide those services.

Mr Jim Wilson: A last quick comment: With respect to the amendment that this group is proposing, what are your thoughts on that? Their point is that it sounds like they're constantly re-educating district health councils about what their rights are and they'd like to just be able to point to this act and say, "This act reaffirms our rights."

Mr Wessenger: I think it would be unusual to provide for a provision in one particular piece of legislation when you have an all-encompassing legislation that covers all other legislation in the province. Certainly, we can have legal counsel look at the situation to see if there's any reason why it would have to have a specific mention.

M. Deslauriers : Merci beaucoup, Charles. Au plaisir de se revoir.

Le Président : Merci. Au plaisir de vous voir encore pour une autre présentation devant un comité législatif.


The Chair: Members of the committee, we are approaching not only the final presentation for today but the final presentation of these hearings. I want to call on the representatives from the York Region District Health Council which, Mr O'Connor, may or may not be an appropriate way to end, but here we are with York region.

We want to welcome you both to the committee, and if you would be good enough to introduce yourselves and then please go ahead with your submission.

Mr John Rogers: My name is John Rogers. I am the chair of York Region District Health Council and I'm also here particularly as chair of the Central East Regional Group of DHCs, commonly referred to as CERG. With me this evening is Graham Constantine, who is the CEO of York Region District Health Council and is also the chair of the central-east executive directors' group.

CERG is comprised of members of the six district health councils in the central-east planning area and includes Durham, Haliburton, Kawartha and Pine Ridge, Metropolitan Toronto, Peel, Simcoe county and York region. Its population represents approximately 44% of the provincial total and contains some of Canada's fastest-growing areas. In 1991-92, almost 45% of the total expenditures in health care were allocated to this region. Additionally, it has the largest multicultural population in the province and is challenged by having to meet the needs of large urban populations as well as sparsely populated rural areas.


The Central East Regional Group of District Health Councils supports the amendments to the Ministry of Health Act, in particular section 62, since the amendments by and large fulfil the spirit and content of the joint task force report. In 1992, the Association of District Health Councils of Ontario and the Ministry of Health, with the participation of the Ministry of Community and Social Services, established a joint task force.

The purpose of the task force was to define the role and mandate of DHCs, to identify resources required to fulfil their mandate and to strengthen partnerships involved in health system reform. The results of these activities were outlined in the report, Moving Forward: Strengthening Health Planning in Ontario. The report was released in the summer of 1993.

The task force concluded that the ability of DHCs to successfully discharge their responsibilities in planning and providing advice to the minister depended on having a clear statement of those responsibilities and their delegation by the minister to DHCs. Many of the issues raised by the joint task force have been adequately and accurately reflected in the proposed legislation.

These issues addressed include the formal recognition of DHCs as a lead planning and advisory body to the Minister of Health, the need to reflect the diversity of the community on DHCs and the recognition that groups other than providers need to be visibly represented. The functions of DHCs outlined in the legislation reflect the actual tasks undertaken by DHCs and the guidance of standardization of composition, recruitment and selection of members of council and committees.

The purpose of our presentation today is to draw to the attention of the standing committee on social development one significant issue that was addressed in the joint task force report but needs to be enhanced in the legislation or the regulations under the act. Under the heading of "Accountability" on page 9, the joint task force report states:

"The accountability of DHCs to both their local communities and the Minister of Health requires them to have latitude in planning for local needs within provincially determined policies, guidelines and standards. In order to function credibly and effectively, DHCs and the ministry must ensure clear channels of communication are established between both themselves and with the local communities. The planning and decision-making processes of the DHC and the Ministry of Health must be defensible to the public they serve, with strong evaluative components built in. DHCs will facilitate strong local input and participation through broad community membership that reflects a diversity of skills, experiences and interests, and through enabling mechanisms to orient and educate council members in fulfilling their responsibilities."

The joint task force report acknowledged a dual accountability of the DHCs to both the local communities and the Minister of Health. In our opinion, the current amendments to the Ministry of Health Act do not adequately recognize the district health council's responsibility to its community.

DHCs have been criticized by DHC detractors as not being locally accountable, on the basis that they comprise non-elected boards. Unless there is a clear recognition by the Ministry of Health of our responsibility to the community, CERG is concerned that our detractors will be able to argue that their accusations have been verified. Responsibility to the community is one of the principles upon which DHCs were built. It should be acknowledged in the legislation.

While the DHC will always remain accountable to the Ministry of Health for providing health planning advice reflective of our local area, DHCs see and must be seen to have a further accountability to the communities they serve. This means that how we do our planning and whom we involve become as important as the recommendations themselves. Ultimately, we will have been successful in our planning processes if the final plans or strategies that are developed are perceived as belonging to the community and not only to the district health council.

While we recognize that we are accountable to the Minister of Health to prepare a plan and identify priorities for our district's health needs, the DHCs also see themselves as having responsibility to the community for the specific contents of the plan. We are increasingly convinced that the key to our success lies not only in strengthening our government mandate, but in improving our linkages with the community.

While the amendments to the Ministry of Health Act strengthen our relationship to the government, there is no counterbalancing acknowledgement of our relationship to our communities.

We would suggest that modification be made to the wording in the legislation or the subsequent regulations so that the DHC's accountability or responsibility to its community is acknowledged. District health councils are more than just another government agency located in a specific district.

In closing, I'd like to reiterate the support of the six DHCs in CERG for the proposed amendments to section 62 and assure you of our ongoing commitment to planning for the health needs of the population we serve.

We appreciate your attention and would be pleased to answer any questions you may have.

The Chair: Thank you very much, and I'd just note for the record that the presentation is on behalf of the Central East Regional Group, as much as York region is a part of that.

Mr Rogers: Yes.

The Chair: Ms Sullivan.

Mrs Sullivan: I thought it was Mr Wilson's turn but I guess because he went, we're going backwards. Are we?

The Chair: He wanted to practise his French.

Mrs Sullivan: I'm very interested in the approach that has been provided to DHCs in the bill, which in fact creates almost an arm of the ministry without accountability to the community, and that's an issue that you have raised.

I'm also quite concerned that in many communities across Ontario, most people don't know what the DHC is, what the powers or responsibilities or mandates are, nor how to participate in putting their information into the process of formulating regional plans to send on to the minister. Your community in York is very similar to mine with both rural and urban components, and I wonder how you see actually making a DHC more accountable to the community and ensuring that the community understands how participation is available to it.

Mr Rogers: I think there are a couple of ways to do that, and in any situation you have to determine how well known a particular group or body is. I know when I was involved in politics that they did a study and found out that maybe I was the most recognized person by having 60% of our community know who I was, but the other members of council were down at maybe 10% or 5%; and so even in politics, which is sometimes quoted as being the accountable profession, it's very difficult to get that recognition.

So what we have to do is make sure that when we both form the district health council itself and when the appointments are made to the district health council, you do look at what that particular district is made up as far as the cross-section of the population, the ethnic mix, the geographic locations -- all of those things have to be looked at -- and make sure that the appointments to council are reflective of the community that that particular council is going to be serving.

Another way of doing the recognition factor is to make sure that you involve as many people in processes as possible, not just the district health itself but the subcommittees of the district health council. In York region, which is a fairly new DHC, which has been in existence for approximately two years now, we've gotten 800 people to participate in different planning processes that we're involved in; and 800 people in our community, even though it's 550,000 at the moment, it doesn't sound like a lot but I think most of you would appreciate that that's a fairly substantial number of people to get involved in health planning issues. They're representative of the provider community, the consumer community, and the municipal governments are involved. We do get a fairly aggressive use of publicity through the media, through local cable programs, those sorts of things that we try to get the numbers of people knowing what a DHC is all about and what their role is to respond and give us their views.


Mrs Sullivan: I find it interesting that the district health councils have been given the responsibility, frequently without the resources, to conduct massive planning efforts, and it's not atypical. It could be the Niagara Escarpment Commission in my community, by example, where you want a lot of community participation in determining the future of the plan and only 300 or 400 people are involved and it's considered to be a big victory. I don't think it's a big victory.

One of the things that I'm very concerned about is that the report with respect to DHCs didn't involve the public. It involved people who were in DHCs and it involved people in the ministry, but there wasn't a broad representation of people who were even asked to participate or comment. It was kind of internal.

There certainly is discussion, through reports such as the Orser report and the Lawson report, of moving into a regionalized funding envelope. Many people see the DHCs as being an approach to moving to that system, and this bill certainly doesn't go anywhere near in that direction. I just think that if those kind of regional plans are ever contemplated, even for a pilot, people have to know what the existing organization does and feel that there's credibility in the community and not just in the minister's office.

Mr Rogers: That again is up to each individual DHC perhaps, but citing the example in our particular situation with long-term care, our long-term care committee has had very broad representation in the community. We advertised into the community and made sure that people had as many opportunities -- we used every paper, which is eight or nine, in the area to advertise for people who wanted to sit on the committee. We've been going out to open houses and consultation, where we go out to the communities -- we don't just sit in our particular location -- and do those sort of things. It's not that we're the only ones that do that; a lot of DHCs do that.

The meetings are open to the public, and that perhaps is where the regulations could help, in making sure that there is a set of guidelines that establishes that the meetings are open, that there is some way that there's accountability clearly defined, and that's again through selection of the members, through the ability of people to make presentations or come to the district health council and have their views known so they can be passed on to the minister and allow the decisions to be made by the minister.

Mrs Sullivan: I guess one of the other things, if I can just say, that I was disappointed in was that there wasn't, through the legislative process, a larger opportunity for a wider public discussion of DHCs, that the DHC issue is buried in this bill rather than being considered separately, so that we could have public hearings and see where they can be strengthened or where in fact people wanted to see the DHCs going, because it really has been overshadowed by the long-term care issues.

Mr Rogers: We should comment that the DHCs, I think, are happy that we were able to get something into legislation --

Mrs Sullivan: I know that.

Mr Rogers: -- because it's been 20 years that we've been waiting and we finally got something.

Mrs Sullivan: I understand that.

The Chair: Because you're the last witnesses, the Chair is going to allow two more questions.

Mr Jim Wilson: Thank you for your presentation. I really do appreciate your comment with respect to wanting a counterbalance and acknowledgement in the legislation about your responsibilities and accountability to the community too, because I have to tell you that -- and it's more of a request, and you as a politician may appreciate this -- I've surveyed my caucus as Health critic over the last few months informally about their relationship with DHCs. I think it would be in the interest of DHCs, and perhaps members, but I think it's going to take DHCs to carry the ball on this, to perhaps in the interest of greater community accountability include their MPPs more, because when people are frustrated with decisions by the DHC, they come to us, as you know.

I'm a little frustrated right now in terms of the central-east dialysis study, which has been -- not your fault -- delayed and delayed and delayed. The reason you're doing that study is because of a private member's bill here by me and other people who participated in the social development committee. I get no feedback from the DHC process and when I talk to individual members, they're to keep it confidential because it's a study and it's advice to the minister.

I wonder on an ongoing and maybe formal way if DHCs -- for instance, my local DHCs never invited me in, Simcoe county, in spite of me talking to the executive director and other people. I know they had Mr Wessenger in because he's the parliamentary assistant to Health, but he's not going to be the parliamentary assistant to Health next year. It's just really a plea to -- because so many groups come to us every week and keep us informed of what they're doing and I just always wondered why DHCs -- maybe you're just too busy; I know you're swamped and there's probably a good reason -- don't, like school boards do, invite us in regularly and tell us what they're up to. I think it would be in your interest because a lot of members don't know exactly what DHCs do.

Mr Rogers: I happen to have two of our members here in this particular committee, so I think we do try to keep them up and I don't think we've ever had any problems with communication. But I think it's a valid concern that each member should be kept up to date. I don't disagree with that and I think it's something that DHCs should be made aware of. I'd be happy to bring it up; we have an Ontario meeting at the end of October. I'll be happy to bring that concept forward then.

Mr Jim Wilson: It's just that we get ongoing newsletters and reams of reports from all kinds of groups out there, and yet when you go to do something on the health side for your community, you're bound now, by soon-to-be-legislation but by the process now, to go through your DHC.

I've said and I'll say it here: Who made the DHCs god? The fact of the matter is, MPPs hold townhall meetings. We have good ideas of what should be done for our health care system and it is somewhat frustrating to think, my God, now I've got to go through this whole DHC process. I can't be a member of the DHC. I could attend the meetings and that sort of thing, but you almost don't want to do that because you don't want to bring undue influence. We're not supposed to go to municipal councils and scream about roads that aren't paved in front of our houses and stuff because we're bound by conflict acts that we lose certain rights to.

So if you could take it back to have them on as regular a basis as they can to just keep members informed, I think it would help all members of the Legislature understand what DHCs are all about.

Mr Rogers: Just generally speaking, within the system, there's a manual that's been produced just recently by ADCO, the Association of District Health Councils of Ontario, that is a media-public relations sort of thing. Public relations includes information giving and making sure that things such as newsletters are perhaps generated on a more regular basis so that they can be sent out to members of the provincial Legislature, members of Parliament, to all of the various spots where people would like to at least be kept informed. These are the sort of things going on and if they're interested in a particular issue, then they can call in and deal with it.

Mr O'Connor: I appreciate you coming before the committee today. Yes, DHCs have been around for a long time and finally there's a government that's willing to recognize it in legislation. In fact, York region went without a district health council for a long time until the present government saw fit to recognize all the hard work that was done in the community and to see it finally up and running.

It's a pleasure to see you again, John, because quite often York Region District Health Council has made presentations to this committee. So you certainly are well involved within this committee and within the community.

In going along with what Ms Sullivan had suggested, I'm going to give you an opportunity to explain to our viewing audience, whoever may be out there watching, exactly what some of the subcommittees are that people could be involved with in the local planning process, in the local committees that do have a role to play in health care in our communities. Maybe you could share with our viewers exactly what some of those committees are because I think that this is a very important place for the community to have direct input, consumers to have direct input so that you recognize the value of that input as well.

Mr Rogers: And I should qualify that you asked me a question on something that is up to each to DHC as to what committees or subcommittees they may have, but as an example, I'll certainly quote to you what we do in York region.

We've looked at the fact that there are so many issues in health care that you're not able to respond to every one of the issues that are out there right at the present time. So we've prioritized, and at this point we have an acute care committee which is undertaking a major study on acute care needs within the region of York, and that committee is certainly open to membership, either right on the subcommittee or we have focus groups, special subcommittees of that committee, to help in specific areas.

We have that particular committee in the acute care field, and we also have obviously in long-term care, it's a major committee at the present to look at the question of MSAs and long-term care within the region of York. That committee's enormous as far as the number of participants in it. The committee itself is, again, reflective of the community and is fairly sizeable: 20 to 25 members.

Then the other major field that we're into is the mental health field as well. There's a group called Co-Ad in our community that is open to voluntary membership as well as the subcommittee on the mental health reform that's now coming down, and we have membership to that and we advertise for all of those as far as participation from the community.

The other area that we deal with as our fourth priority is the area of healthy communities. That's a little bit more broad-based, but it's to look at how you get people in your communities up to a healthy living standard. That's looking at determinants of health and, once you know how your community fares in the health status reports, then how you improve the areas that need improvement. So those all are open, again, to membership from the community.

Mr O'Connor: Thank you very much. I appreciate that, and I think there are a lot of ways that people could be involved in local planning processes through a district health council. I encourage any of our viewers, having heard some of the areas that our district health council has to offer their involvement in, to call the district health council up and do get involved.

Mr Rogers: Yes.

The Chair: As the Chair and having the last word, I would just simply underline, and I think Larry would agree with this, that perhaps it's partly because you are one of the newest or almost the last, I think, save one, of the district health councils, and I think all the members from all political parties have found that we've been able to develop a good working relationship, and I think that does underline the points that our colleagues made.

Probably one of the interesting things that we will all face -- district health councils, legislators and indeed municipal governments -- because I think one of the interesting things that you have done, just to add as well in terms of how you try to represent the community, is the agreement that you have with the regional municipality of York and with the York Region Community Services Council, which I think is aimed, in a large part, at making sure everybody knows what everyone else is doing. I think that as the responsibilities of district health councils have evolved, that broader community sense of understanding and knowing increases, and I suspect that all of us will be involved in that ongoing debate.

As I said at the beginning, you're our last presenters, and that just led us into philosophical areas. But may I, on behalf of the committee, thank you both very much.

Mr Rogers: Thank you very much, Mr Chairman.

The Chair: And that, dear friends and gentle hearts, brings us to the end of the presentations. I asked the clerk, and I just thought it interesting, in terms of the number of presentations that we've had. We've had 227 presentations but some of those have been joint groups, so we probably have been able to get, between individuals and organizations, something in the range of 250 and virtually all those who did ask to appear before us. So we have gone through our own long-term care, I think, and I want to thank everyone.

Just to remind members that clause-by-clause will begin on Tuesday, October 25, and October 25, 26 and 27 are the scheduled days. I will be in touch with the members of the subcommittee and we'll organize the exact time and some other matters around that. But with that, the committee stands adjourned until October 25.

The committee adjourned at 1805.