CONTENTS
Wednesday 30 October 1996
Ministry of Health
Ms Margaret Mottershead, Deputy Minister
Health Services Restructuring Commission
Dr Duncan Sinclair
Mr Mark Rochon
STANDING COMMITTEE ON ESTIMATES
Chair / Président: Curling, Alvin (Scarborough North / -Nord L)
Vice-Chair / Vice-Président: Cordiano, Joseph (Lawrence L)
*Mr TobyBarrett (Norfolk PC)
Mr GillesBisson (Cochrane South / -Sud ND)
*Mr JimBrown (Scarborough West / -Ouest PC)
Mr Michael A. Brown (Algoma-Manitoulin L)
*Mr John C. Cleary (Cornwall L)
Mr TonyClement (Brampton South / -Sud PC)
Mr JosephCordiano (Lawrence L)
*Mr AlvinCurling (Scarborough North / -Nord L)
*Mr MorleyKells (Etobicoke-Lakeshore PC)
Mr PeterKormos (Welland-Thorold ND)
*Mr E.J. DouglasRollins (Quinte PC)
Mrs LillianRoss (Hamilton West / -Ouest PC)
*Mr FrankSheehan (Lincoln PC)
*Mr WayneWettlaufer (Kitchener PC)
*In attendance /présents
Substitutions present /Membres remplaçants présents:
Mr BillVankoughnet (Frontenac-Addington PC) for Mrs Ross
Also taking part /Autres participants et participantes:
Mr David S. Cooke (Windsor-Riverside ND)
Mr MichaelGravelle (Port Arthur L)
Clerk / Greffier: Mr Franco Carrozza
Clerk pro tem / Greffier par intérim: Mr Douglas Arnott
Staff / Personnel: Ms Lorraine Luski, Mr Steve Poelking, research officers
Legislative Research Service
The committee met at 1535 in committee room 2.
MINISTRY OF HEALTH
The Chair (Mr Alvin Curling): We resume the estimates of the Ministry of Health, vote 1401. When we broke off the last time, there was an hour and 29 minutes left, but with my power, I will rule it is an hour and 30 minutes, which we'll do it in rotation.
I want to welcome the commissioners. I'm going to ask you to state your name and title for me.
Dr Duncan Sinclair: I'm Duncan Sinclair, and I'm the chair of the Health Services Restructuring Commission.
Mr Mark Rochon: My name is Mark Rochon. I'm the chief executive officer of the commission.
The Chair: Welcome to the committee. I'm going to do a rotation of 30 minutes, 30 minutes and 30 minutes. We'll start with the opposition.
Mr Michael Gravelle (Port Arthur): Dr Sinclair, Mr Rochon, welcome. It's good to see you here and good to have the opportunity to talk to you and ask you some questions. As you know, I'm from Thunder Bay. Obviously, the first stop of the restructuring commission was in Thunder Bay, so there's a lot of issues that are of great concern to us.
If I could begin with a pretty straightforward question to you, Dr Sinclair, is it your opinion that a ruling of the Health Services Restructuring Commission can be overturned by the Minister of Health?
Dr Sinclair: When you refer to a ruling, I presume you mean a decision, because we're empowered to do two things: One is to decide on hospital restructuring, and the other is to make recommendations on the restructuring of other elements of the health services system. With respect to a decision, that's not appealable, as I understand it, to the Minister of Health or to anybody else.
Mr Gravelle: So a ruling/decision, you would say, cannot be overturned by the Minister of Health?
Dr Sinclair: That's correct.
Mr Gravelle: What do you think it would take to overturn a decision of the commission? In other words, the decision's been made -- and you're quite right: There's a distinction in the report, certainly in Thunder Bay's terms, between decisions and recommendations. But if you're saying that indeed the minister cannot overturn a ruling or a decision by the commission, what would it take to have a decision of the commission overturned or changed or whatever wording you'd like to use?
Dr Sinclair: As I understand the legislation under which we operate, the decisions of the commission are in fact final, and I would presume that they could be altered by virtue of the fact that the commission were disbanded or, I presume, through the process of judicial review or some other process like that outside the ordinary work of the Legislature.
Mr Gravelle: Just following up slightly in terms of the recommendations, I know various decisions have been made and various recommendations. It seems to me that the reinvestment issues are recommendations.
Dr Sinclair: That's correct.
Mr Gravelle: In other words, the decision in Thunder Bay's terms to withdraw $40 million-plus is viewed as a final decision that cannot be overturned, but the reinvestment is simply a recommendation that still has to be argued for with the ministry. Is that correct?
Dr Sinclair: Our recommendations are in the same category as decisions, with respect to the power of the commission to make them. I don't believe anyone has the power to require us to change a recommendation, but a recommendation is in fact just that. Whether action is taken on those recommendations is not within the power of the commission; that's within the power of the body to whom we're making recommendations.
Mr Gravelle: Do you believe the commission needs to show some flexibility, though? For example, in terms of some of the deadlines you set, there were 30-day deadlines and other deadlines, and it seems to me that there was some flexibility. Obviously, in terms of the community's response, Thunder Bay, as you know, responded in an extremely dramatic and I think very responsible way. I probably quite literally bombarded the commission offices with submissions in terms of the appeal process. But do you think that some of the timing issues of the commission need to be more flexible?
Dr Sinclair: The commission's procedures are set up to provide for an opportunity for affected communities, institutions, to comment on our initial reports in a period of 30 days and to provide us, basically, with data and information that would say, "Show us where we're wrong." The data and information that we or anybody else would have to operate on are never perfect. We also are aware that the most likely source of information that would show us to be wrong is in the affected communities or organizations. So we've provided that period of time for people to provide us with data and information to say why we were wrong, whether we were wrong in the detail of what we've recommended or in the time lines we have made in connection with our decisions or recommendations. So the commission is quite flexible on that. But we are, I think, clear in our own minds that restructuring needs to proceed quite quickly. If the case were to be made, supported by data and information, that a particular deadline is too short, too long or whatever it is, we would certainly be prepared to look at that, provided the information were provided to us during that 30-day period.
Mr Gravelle: There certainly is a number of issues, and as we go through my time I'd like to ask you about some of those specifically. But the area I'd like to get into next is the funding decisions you brought down in Thunder Bay in relation to, specifically at this stage, the capital costs in terms of the building of the hospital. The decision was basically to have a renovation or expansion on the one site, the Port Arthur General site of the Thunder Bay Regional Hospital. I think $64.3 million was the figure you came up with as being the capital cost for the building.
I recall asking Mr Rochon, the day of the press conference in Thunder Bay, just how you knew these figures were the right figures. You didn't feel you were in a position to give me a real response. But one of the things that concerns me is that even in your own documentation on which you based your decision on the costing -- I think it's RPG Partnership. They came out with figures for what the cost would be for the renovation and what the cost would be for a new site, what you called a greenfield site.
I think $109 million to $113 million were the figures that were provided to us. Actually, my colleague in Fort William asked for the information; Lyn McLeod asked for this. The information came out that in terms of cost, it would be $109 million to $113 million for a new site. Yet, on October 4, in your press release and quite publicly, you stated that one of the reasons you made a decision to go with this expansion or renovation was that the cost for a new acute site would be $180 million.
That strikes me as very disturbing. If indeed your own figures had $109 million to $113 million being the cost for a new site, which was quite calculated in your findings, to use $180 million strikes me as -- well, I'd be curious to know where you came up with the figure of $180 million, because you use it in your press release. Where did you come up with that when the other information you were working from seemed to indicate $113 million was the maximum you expected it to cost?
Mr Rochon: The $180-million estimate was a combination of two things. It's the addition of the development of a new cancer centre, the addition of site development and so forth. It also is based on the estimates that the Thunder Bay Regional Hospital had developed as well. Those are Thunder Bay Regional Hospital estimates that came to the $180 million.
In part, the calculation and the estimates that Thunder Bay Regional Hospital put together excluded the cost of developing a new regional cancer centre. I know you're aware of that. In Thunder Bay, they've just recently finished an expansion and renovation of the cancer centre. The cost of reworking a new cancer centre at a greenfield site would be an additional $25 million to $30 million.
Mr Gravelle: But even if you use that example, and I presume that was part of it, we're still looking at $155 million if you take the $25 million off the $180 million. What I'm working towards, without in any sense meaning to be rude, is that it just seems to me that the figures were being used to say, "All we can really justify is the $64 million because this is so expensive." It gave the impression of playing with figures. When we discovered that the figure you were working from, based on the RPG Partnership material -- we managed to gather that through freedom of information -- was $113 million, even if you add $25 million to that, you still don't get to $180 million. It strikes me that these were figures that were not being used before and just weren't accurate and weren't based on anything other than an estimate.
Mr Rochon: No, they were estimates provided to us by the hospital, quite frankly. The Thunder Bay Regional Hospital provided us with those estimates and we used them.
Mr Gravelle: But why would you use those when you had figures -- your consulting firm gave you figures that you were using, and I'm sure you'd want to use figures that are accurate, obviously.
Mr Rochon: Absolutely. But I think you'll appreciate that in this discussion at this particular point in time we had estimates that we had produced, there were estimates that the hospital had produced, and we're talking about a range of estimates. From our perspective, what we are talking about in Thunder Bay is a significant cost difference between an option that would see us redevelop the Port Arthur General site and a greenfield site, and that's what drove the decision.
Mr Gravelle: I certainly appreciate that. One of the concerns we have is the $64-million figure. I asked you how you reached that. As you will recall, you had a very nice drawing of your conception of the new hospital, which of course ran in the newspaper the next day and people used it. We've since learned -- we asked for the architectural and engineering designs for that. I understand you were not working from that, that this was an artist's rendering.
Mr Rochon: Absolutely. It's an architect's rendering, and we said that. In fact, when we were discussing this with the media and with the individuals in Thunder Bay we said, "This is one person's conception of what the hospital could look like." There are no engineer's or architect's detailed drawings behind that. It's what is usually done at this stage in putting together a conceptual idea of what a hospital, or any building, might look like at this stage.
Mr Gravelle: But it makes it more difficult to establish that the cost will be a certain amount, it seems to me.
Mr Rochon: No, I don't think it does, because what we are working with, in coming to grips with the estimates for 200,000 additional square feet, is industry standard -- industry standard in terms of the square footage requirements per bed and industry standard in terms of the cost per square foot -- plus allowances for what might be referred to as a northern factor, given where you're located. Those were estimates that we put into the equation to help us determine the estimates relating to the redevelopment.
Mr Gravelle: As far as you're concerned, you're both comfortable in saying on the record that a new site would cost the figure you used in your press release, regardless of the fact that -- again it seems like you're cobbling figures together here in terms of the $180 million.
Mr Rochon: No. I know what you're talking about. The estimate in the press release was based on information provided by the Thunder Bay Regional Hospital. That is the upper estimate they gave to us. We're using estimates that the Thunder Bay Regional Hospital used, to establish a range.
Mr Gravelle: But you did just say the "upper estimate."
Mr Rochon: Absolutely.
Mr Gravelle: If you're going to err, you're going to err on the side of the most costly figure rather than the least costly.
Dr Sinclair: If I may break into this, from the perspective of the commissioners it was very apparent that the estimates provided by the Thunder Bay Regional Hospital did not include the cost that would be necessary with moving the newly renovated cancer centre. That really comes as a piece, so that's a significant issue that had to be added in. I don't want to do a C.D. Howe here or anything, but the fact is that it was very apparent, right from the outset when we began to get the numbers, that there would be a substantial premium necessary to build on a greenfield site relative to the cost of adding to an existing inventory.
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We have three major criteria we're concerned with. One is accessibility, ensuring that people have access to services as close to home as is possible. The second has to do with the quality of care, quality of service that can be provided, and there critical mass is a considerable issue, because the data are very clear that those who do things frequently do them better, as a rule, than those who do things infrequently. The third criterion is affordability, and that includes the utilization of the existing inventory of buildings and people and equipment and all of that that's there. In place there was an essentially brand-new extended cancer centre, just finished. That's a major issue.
Mr Gravelle: Absolutely. I was at the opening. It's a wonderful facility.
Dr Sinclair: Whether we're talking here about $100 million or $70 million or $150 million, it remains that there would be a substantial premium to building on a greenfield site over providing funds for the renovation of one of those existing institutions.
Mr Gravelle: I don't mean to belabour it, other than the fact that I think it's important to get it straight. There certainly are other issues I want to get in and I'm conscious we haven't got a lot of time. But the difficulty is that we're looking at a renovated site of 200,000 square feet, 150,000 new and using 50,000 of the old site, correct?
Mr Rochon: It's 200,000 new space and 50,000, substantially renovated, of the existing space.
Mr Gravelle: Did you factor in the Spectrum report? That of course talked about the fact that in terms of using the present facility, the building itself, there might be -- indeed they were very clear that there would be higher costs than expected in terms of using the older building itself, in other words, renovating the older building. I'm sure you're aware of the Spectrum report.
Mr Rochon: Yes, we are.
Mr Gravelle: You factored that in?
Mr Rochon: We understood what they were saying, but I think we have to understand that in the construction and renovation of facilities in Ontario, we have to make sure we use the best available physical plant that's on the ground and in use. In terms of standards, we've had continued debate about whether we bring existing space up to 1990s standard or accept 1970s or 1980s standards.
Mr Gravelle: I will move on to the next area. I just want to make a point: When you're essentially saying we are going to build 200,000 square feet of new space and only use 50,000 of the other and we can do it for $64.3 million, it seems very difficult to understand why, by putting it on a new greenfield site, you're moving up to $150 million. There seems to be a remarkable gap here. You're taking the cancer centre out in terms of that $30 million figure, perhaps.
Mr Rochon: That's one of the issues; the cancer centre has to be factored in. But the other is that we're using more than 50,000 square feet of the existing Port Arthur General site. The existing site is approximately 200,000 square feet. What we said in the report is that approximately 50,000 square feet would require substantial renovation. The balance of the space would be needed, in addition to the cancer centre. The physical plant piece of this is 400,000 square feet.
The point, from our perspective, is that the physical plant is the platform from which we provide service. Part of our decision-making is based on assessments of what is required from a capital perspective, but what we're trying to achieve is to make sure there is reasonable space within which to provide services to the region. The 200,000 new square feet that will be developed on this site is all of the high-tech space. It's emergency rooms, it's diagnostic imaging, it's laboratories, it's operating rooms, all of the areas that are capital intensive and require, in our view, state-of the-art facilities. We're very supportive of the need to invest this money for the future of the people in northwestern Ontario.
Mr Gravelle: Mr Chair, how much time do I have left?
The Chair: You've got 11 minutes.
Mr Gravelle: Oh, God. Quickly: On June 27, when you brought down your first decision, when you arrived in Thunder Bay on June 27, were you operating on the premise that the Ministry of Health capital funding formula was two thirds or 50%? In other words, when you walked in there with your report you were talking about the district health policy in terms of capital funding, and -- there's no point in being coy -- on June 27 it changed from two thirds to 50%. Obviously, it doesn't strike us as coincidental in Thunder Bay, because that makes a substantial difference in terms of building, of capital structure. Were you aware, Dr Sinclair, that the funding formula had changed that day?
Dr Sinclair: I'm not sure I was aware that day, but we knew it changed either shortly after or around that time. But I can assure you that was coincidental.
The issue of who pays is not within the commission's purview. Our concern is to make sure we have capital reinvestment recommendations in place that meet our test of affordability. How the money is raised is really not within our purview. That is a decision, clearly, that will be taken by somebody else.
Mr Gravelle: You must have some consideration for the community's affordability as well, though. If you're not going to factor in at all whether the community can afford it -- obviously, if you're coming in and saying, "Here's what you must do, here's what you must build, here's the money you must spend as a community," and here you are, taking $40 million out of the community, clearly you can appreciate that whether it is to be a two-thirds funding formula or a 50% funding formula is an extraordinarily important distinction. Some would argue that indeed there should be a full reinvestment so that capital funding could be completely covered by the Ministry of Health, because you're coming and telling a community.
Dr Sinclair: Mr Gravelle, there is a sequence of decisions. First, you have to know how much money you need to spend. Our responsibility is to make recommendations on reinvestment that do in fact set what money needs to be spent to get to the kind of standards that Mr Rochon has referred to, utilizing to maximum effect the existing inventory. That we did. Then comes the decision, how is this money going to be raised and who's going to be responsible for raising it?
Mr Gravelle: So it wasn't significant, in a sense, whether a community had to provide one third or one half of the funding for capital.
Dr Sinclair: It was not a factor at all in our decision, because we're taking that first decision of how much money is necessary to provide the facilities necessary to support the service level required in northeastern Ontario.
Mr Gravelle: Again not factoring in whether a community could afford it, with no understanding of the community's ability to --
Dr Sinclair: Frankly, we do not have the capacity to assess the fund-raising capacity of any community. Our responsibilities don't extend that far, nor our authority. What we are charged to do is trying to identify what it's going to cost.
Mr Gravelle: I'm sure you recognize that some communities are certainly in a better position, for a variety of reasons, in that they obviously have capital foundations in different shapes.
Dr Sinclair: Of course.
Mr Gravelle: During the appeal process, which ended July 29, I believe, you did receive a letter from the Deputy Minister of Health on behalf of the Ministry of Health. What concerned us about that process was that the letter in essence supported the decisions of the commission and was pretty clear about that. On the one hand we have the Minister of Health saying, "I'm absolutely independent of the commission's findings," and on the other hand supporting a decision made by the commission.
Do you think it's appropriate, if indeed you are an independent commission whose decisions are your own, to have submissions from the Minister of Health? That's in essence what you're receiving when you have a letter from the Ministry of Health: the minister himself.
Dr Sinclair: First of all, I'd like to say the 30 days is not an appeal period. It's a period during which we invite the submission of data and information that will assist us in converting our interim reports and the final report so that we can ask the question: "Are we wrong? Give us data and information that show us if we're wrong." We really do want to make the best possible decision we can. So it's not an appeal process; it's a matter of giving a time so they could provide information that bears on the decision.
Secondly, we get letters from all kinds of people, and in this case, of course, from the Minister of Health. It's very important to the commission, the commission is very concerned, to ensure that its decisions in relation to hospital restructuring are in fact accompanied by actions on the recommendations we make in respect of reinvestment both of capital and of investment in other elements of the health services system.
It's very apparent to the commission -- and I remind you that we're not a hospital restructuring commission; we're the Health Services Restructuring Commission -- that as you push on hospitals, you'll get a bulge somewhere else in the system, so it is very important that we maintain communication with the Ministry of Health in respect to the actions it proposes to make on our recommendations. In that respect, from the point of view of the commission, I welcome good communication with the Ministry of Health, but that doesn't mean we are dependent on the ministry. In fact we are not; we're independent of them.
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Mr Gravelle: So you think it's appropriate for the Minister of Health to submit his position on each decision you make. You think it's completely appropriate for the minister while, on the one hand, he's saying it's an independent commission? You think therefore it's appropriate for the minister to support a --
Dr Sinclair: Certainly I would invite and have invited feedback from the ministry and the Minister of Health on actions they propose to take on the recommendations. I want to comment on something else: They're perfectly entitled to do so.
Mr Gravelle: So you think it is appropriate and you would invite that?
Dr Sinclair: We've been very open. We accept recommendations and comments of all kinds.
Mr Gravelle: Surely you can appreciate the potential conflict, to say the least, of having the Minister of Health, the Ministry of Health, writing a letter supporting a decision made, when indeed, if I could just carry it a little further, the minister has announced $1.3 billion in cuts to hospitals over the next three years. The restructuring commission is unquestionably, obviously, a part of the connection in terms of how this process is going to be carried out. I'm not by any means being critical of your efforts in terms of what you're trying to do, but the chain follows that therefore the role of the commission is to find a way to do this. I don't think that's particularly even a cynical comment to make. Clearly, one follows the other.
Dr Sinclair: The commission does not have a financial target. Frankly, we would not accept a financial target. We are aware that targets have been set by the government with respect to the hospital sector, but they were set before the commission was established. As I said previously, our approach is to utilize these three criteria: accessibility and quality, and our view is that if we get the first two right, the affordability issue will fall into place. We are obviously aware that there is a substantial financial target out there that the hospital sector has been set, but, as I said, prior to our formation. It would have been wonderful if the commission had been established in better times and we didn't have the pace forced on us by the circumstances that are changing very, very rapidly. But that's then, this is now, so we have to get on with it.
Mr Gravelle: In the short time I have left, and I suspect it is a short time, I want to ask about long-term care. A number of elements of the decisions you've made concern us in Thunder Bay. Certainly the acute care numbers are of great concern to us. We won't have time to discuss that, but they certainly are.
Long-term care is the one that seems to be a missing element in there. You certainly have reduced the number of chronic care beds presently in place. There is going to be a transitional period, clearly, when there are people who will not be able to be in chronic care and who you say shouldn't even be in long-term care, including some people who were in acute care who you believe should be in long-term care. But we all know there aren't the facilities in place, there aren't the beds in place. We know that provincial cuts have threatened homes for the aged. We know that's a problem. It seems to me you haven't dealt with that. The restructuring commission has not dealt with the fact that the transition period will not -- that some people are going to fall through the cracks is the greatest concern we have. There just aren't the beds. You can't just kick them out. I've got lots more I could say, but if you could respond to that, I'd be grateful, because that's a very real concern in our community. It seems wrong.
Mr Rochon: It's a significant issue for us as well. In part, we have, through our advice to the minister, recommended significant investments in home care, an addition of approximately 20% over the current budget.
Mr Gravelle: I don't mean to be rude, but some just can't go home.
Mr Rochon: That's correct, and that would result in approximately 37,000 additional home care visits for chronic care patients in their homes.
The other piece of this relating to chronic care in institutions is that the district health council and the providers recognize that there were probably too many chronic care beds in Thunder Bay. The reductions that we directed were to a range. The community said, after we had issued our notices in June, that rather than about 180 chronic care beds, the number should probably be about 120. We said, "It should probably be about 90, but let's work it out over the next three to four months to see if we can come up with whether it's 90 or 120 or somewhere in between." We've asked the hospitals to work with us on that piece as well.
Mr Gravelle: But it's the --
The Chair: Mr Gravelle, sorry, we've run out of time. Mr Cooke?
Mr David S. Cooke (Windsor-Riverside): Thanks for coming to join us for a couple of hours this afternoon. I have a few questions that I hope you can help me with. A couple of them flow out of Mr Gravelle's line of questioning.
Under Bill 26, you have the power to close hospitals, right? That's basically the power you have.
Dr Sinclair: That is included, but it can also be to have hospitals change, rationalize programs among themselves and do a variety of other things. But that is included, yes.
Mr Cooke: But you don't have any responsibility or powers to enforce the other half that is important for hospital reconfiguration, and here I'm talking about reinvestment at the local level and capital from the provincial government. So you could make a decision on Thunder Bay or Sudbury -- and I'm not encouraging you to come down to Windsor. I hope, actually, that you don't come anywhere near Windsor, because we've already gone through all that, not because we wouldn't want to have you visit.
Mr Rochon: Some of my best friends are there.
Dr Sinclair: One of our commissioners comes from Windsor.
Mr Cooke: Some of your best friends are from Windsor, and some of my best friends are probably on the commission, but that doesn't mean I want your best friends or mine to talk.
The concern I have is how you've really only got half a mandate and the difficulty that can potentially cause. It's one thing for a minister to be able to say, "Those decisions to close a hospital are yours and I can't do anything about it even though I totally disagree with you." In the end, notwithstanding Bill 26, if a minister wants to say that a hospital is going to continue to be funded, a minister can do that. Regardless, with Bill 26, I don't know how you can make sure these things are going to happen. The decision to close a hospital is the easy decision. I know this from going through it in our community. The rest of it becomes extremely difficult.
Dr Sinclair: Well, Mr Cooke, you've hit on a point that is of great concern to the commission. Not that we're anxious for more power, as there are many people in Ontario who think we have already too much as it is, and that which we have is awesome. But it is vitally important, as you pointed out, that these two shoes, as it were, hit the floor pretty close together. As I said to Mr Gravelle, if you push on the hospital system and make major changes in the hospital system, there will be impacts elsewhere in the health services system: on home care, on long-term care, physician services, all kinds of things.
So we have been very deliberate in our reports to date to include in those reports decisions and recommendations, and we're all learning by doing here; we don't have an awful lot of record. As chair of the commission, I'm confident that actions will be taken on our recommendations. If I were not so confident, frankly, I would have to reconsider all the work we are doing, because it's very apparent that both of these shoes should hit the ground pretty close together. Of all the things that are of concern to the commission, this is very high on the list, for very obvious reasons.
Second, it's particularly of concern because the restructuring of the health services system is a very large job, a very large job indeed. Like every other job, you've got to start somewhere, and where we've started is with hospital restructuring. But we plan, over the course of our four-year mandate, to in fact address other elements of the system, and they do not come seriatim. We're very concerned at this early stage to ensure that our work will contribute positively to the restructuring of the whole system, the design of which we hope to leave as the mandate when we sunset in April 2000.
Mr Cooke: What commitments have you been given in terms of capital for Thunder Bay and Sudbury?
Dr Sinclair: We've been assured that action will be taken on our recommendations. We have had discussions with representatives of the ministry, and those discussions have been reassuring to the extent that we believe actions will be taken as we have recommended or very close to it, or at least we'll have some reason why there is some modification of those. I'm quite reassured. But I'm very anxious, as you are, from your question, to see some of those actions, and soon.
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Mr Cooke: From my recollection of being in government, capital budgets don't always remain solid with ministries. In education, our budget was always taken away so that it could go to health. But maybe I could just ask the deputy in relation to this, what kind of shape is your capital budget in? The Ontario Hospital Association estimates -- and maybe Dr Sinclair can confirm this -- that the restructuring process will require at least $1 billion in capital to restructure the hospital system. Since they've got the power to close hospitals and you've got all the power to implement, basically, where are those two things coming together, and are they?
Ms Margaret Mottershead: Yes, they are coming together. The government has committed that the capital that is required to implement the hospital restructuring will be made available. That is a commitment that I think you'll get more information on in the next few days or even weeks, but the whole plan is being put in place. In terms of supporting the commission, having been in government, Mr Cooke, you would know there is a cycle in terms of budgeting that comes with estimates and so on, but I think the government is so committed that it's actually reviewing all of its capital requirements in order to make hospital restructuring happen ahead of the cycle.
Mr Cooke: What's the capital budget this year for the ministry?
Ms Mottershead: It's $167 million.
Mr Cooke: And you haven't got a capital budget for next year yet, at least that's been public.
Ms Mottershead: No.
Mr Cooke: Would you agree with the Ontario Hospital Association that the ballpark figure would be about $1 billion?
Dr Sinclair: Mr Cooke, at this stage we're working hard to try to get an estimate of our own. That seems to me to be, as you say, ballpark, maybe even "the same city" kind of estimate. I have no idea at this juncture. It will not be cheap. But we also know that the capital reinvestment, relative to the operating efficiencies -- the operating efficiencies are, in my view and in view of the commission, generally pretty substantial, so if one looks at the big picture, as one would with a business, the capital, I don't think, will be particularly daunting. Now, it may be daunting in terms of cash flow for the government -- that's a question that the deputy and others would have to answer -- but in terms of the system and the broader interest of the people of Ontario, I don't think the capital reinvestment or indeed the reinvestment in elements of the health services system other than hospitals are particularly daunting relative to what would be the case in most "businesses" of this size. This is a very large enterprise.
Mr Cooke: Yes, but there are all sorts of things that can interfere with this. This whole process is going to take several years by the time it's actually implemented. You're at the very beginning of it. Who knows what the economy's going to look like two or three years from now and whether we're into another recession, and then governments tighten up capital budgets. All of that has to be anticipated. No criticism of you, but it doesn't make me feel very comfortable to think we're on our way into the restructuring process and we still don't have a fairly solid number to go to government and say, "Here's what we think you'd better start looking at for capital over the next three or five years." If you get down the road on this and the government hasn't put that into its multi-year capital budgets, I think you're in deep trouble.
The other part that you didn't really answer, I don't think -- you made a comment to Mr Gravelle something along the lines that you have to make a judgement of whether the capital requests or needs are affordable. Well, affordable to whom? In Thunder Bay and in Sudbury we're looking at the local capital requirements just for hospitals -- and surely you understand that because of lots of other decisions that governments are making, there are other organizations, in community services and educational services, universities, trying to raise capital as well -- but just in the hospital system we're talking about $500 to $600 per household to fund the restructuring capital that's required in those communities. In Windsor it's the same. So when you say you feel comfortable that it's affordable, how? If that money can't be raised at the local level, this thing all goes down.
Dr Sinclair: Mr Cooke, I share your concern about how the resources will be raised, but let me put in context the concern of the commission. When we began our work, we spent considerable time trying to get our mind around the status quo and what is happening in the status quo. Frankly, it's our firm conviction that without restructuring of many elements of the health services system, beginning with our hospital system, the costs will go right out of sight. We believe with the restructured system, one of the goals here is to make it affordable, and our current system is just not affordable.
Mr Cooke: You don't have to convince me.
Dr Sinclair: Money will be required from the people of Ontario. Whether directly out of their pockets or through the tax system, it will be required. There's no question that the citizens of this province, at least in my opinion and in the opinion of my fellow commissioners, put a great deal of priority on the availability of health services. It's almost a defining characteristic of Canadians, as well you know. To repeat my answer to Mr Gravelle, our principal responsibility at this juncture is to try to put some estimate on what the cost of restructuring is, yielding the three criteria of accessibility, quality and affordability. It's our view that that last estimate of affordability is a lower estimate than the cost that would be incurred by the system in trying to maintain the status quo.
Mr Cooke: I'm not here to advocate, and I don't think the record of our government when we were beginning to restructure the health care system was one of advocating, the status quo.
Dr Sinclair: I didn't mean to imply that in the slightest.
Mr Cooke: But what I always try to look at with a public policy is, at the end of the day is the public policy practical enough that it's actually going to work? I'm focusing on the capital because I believe that if the capital isn't available and if you can't raise -- I mean, if the goal of the government is to save money on the operating side and reinvest in the community, and that's what we all support, it was to me a counter-productive policy change to go from 66% of capital funding at the provincial level to 50% when there's such a huge demand for capital. You know as well as I do that governments, if you're putting together budgets, you'd rather experience a one-time capital expenditure than an ongoing operating expenditure. What they're doing here, I think -- I know you're not a politician --
Dr Sinclair: Thank goodness.
Mr Cooke: -- so you're not here to defend or attack the government. But my concern is that by that policy change, your work is now being put at risk, because I think the capital demands on the local level are not achievable.
Dr Sinclair: The decision to change the sharing formula was not that of the commission. I'm not in a position where I can answer that. Again, I can just say that I have received sufficient reassurance to persuade me and my fellow commissioners that the work we are doing will yield the outcome we anticipate in that we do have commitments from the government in terms of actions on our recommendations, and I remain confident. The day I am not confident, frankly, is the day I think we would reconsider just how much work, effort and energy we volunteers are putting into this activity.
Mr Cooke: Well, can I suggest that when you are looking at future communities -- you haven't come up with the final decisions on Sudbury; we're in the 30-day period. I think it would be appropriate for you, based on the 50-50 formula -- and it's not a difficult calculation; you work with much larger numbers -- to look at what the community would have to raise and what it would be on a per-household basis, and you know the industrial and business base, especially in some of the northern communities, is not real strong; to at least make some comment that the capital demands on that community are of great concern to the commission and that the government should look at that.
I don't have a big problem. I can quibble with some of the recommendations and some of the concerns we have about bed numbers and so forth, but the direction is not something I'm arguing about. What I'm more concerned about is whether the implementation is going to be possible because of some of these problems.
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There's another area I'd like to briefly explore with you, and that is the whole question of denominational governance. This is one I became very familiar with in my home community before Bishop Henry headed up to Thunder Bay. I'd like to get some idea of whether you factor this in at all. You know that the minister wrote a letter up in Sudbury; there were comments made that there was going to be some guarantee of a role for Catholic governance. This is always contentious in the province, and I think communities should very clearly understand what the ground rules are that you're operating under.
Dr Sinclair: We, as a commission, have discussed this a great deal. It relates not only to the Catholic health commission, but to the health commission of the Jewish community and the Salvation Army and others. Let me be very plain. We have a single view on this in the commission, without any doubt. We believe very strongly in the value of diversity within the system, and the different governances, the denominational and other governances that apply to hospitals, have yielded great strength in Ontario in the diversity of hospitals and other institutions we have to draw on. There is much to be said -- in fact one could say it's essential to maintain that degree of diversity. Similarly, the cultural background, the traditions, of all the institutions and organizations of our society define what we are. All of that is extremely important. As the spokesperson for the commission I have said that to the Catholic Health Association of Ontario and to others, and I believe it very strongly.
That having been said, however, there is a proviso, and that proviso is that the preservation of diversity and of culture and of tradition should not stand in the way of a greater interdependence of institutions in a given sector, like hospitals, and of institutions and organizations throughout the whole of the health services system. If you do have a system -- frankly, we don't have one now and we have never had one in the ordinary sense of the word -- all its elements have to work together and they have to work together in accordance with the discipline of agreed-upon common goals, objections, mission and policies. There is a key word shift necessary to create a system, and that is from "autonomy" to "interdependence."
It's not beyond the wit of man to figure out how to do both things: to preserve diversity, the benefits of culture and tradition and long history, and create an interdependent system. There are many models currently extant in Ontario whereby denominational and non-denominational hospitals have achieved just that. Our expectation is that that will be achieved in every community in which the denominational hospitals contribute, with others, to the provision of health services in that community.
It's quite apparent to us -- keenly, very apparent indeed -- that in Sudbury there is a concern that our recommendation threatens denominational governance. In our view, that's an overinterpretation of our initial decision with respect to the provision of a single organization in Sudbury to provide for hospital services. We have, in that recommendation, offered the services of the commission to provide for mediation among the participating institutions in that community now to work out mechanisms, and there are, as I say, models in Ontario that do work of how to do both things: preserve Catholic governance and, elsewhere in Ontario, Jewish governance and Salvation Army governance, together with non-denominational governance, in order to produce a genuinely integrated hospital sector within a genuinely integrated health services system. Integrated does not mean homogenized, and we would be very much opposed to that as a commission.
Mr Cooke: Again, while I have no particular difficulty with the philosophy you've just enunciated, I worry about this process taking on so much, and this is certainly one that can force the whole thing in some communities to come tumbling down. I hope you will at some point in some communities decide that to be practical, to be pragmatic may be the better way, of getting some 80% of the way to restructuring rather than trying to do something that may look pure on paper but will never see the light of day because of community resistance.
Dr Sinclair: Mr Cooke, I can assure you that the commission is absolutely committed to being practical in every community. We have that very much in mind, what is an ideal solution and what's a practical solution, and all of our recommendations and all of our decisions are cast with a very keen eye on practicality, at least as well as we can judge it.
Mr Cooke: There are two other areas I'd like to explore. I think I have about eight minutes left. One is the relationship between the $1.3 billion in budget cuts to hospitals and the restructuring process. Then I'd like, maybe more briefly right now, to talk to you about, along the same lines of the capital commitment for restructuring, what the commitment is in terms of dollars for labour adjustment. The line we've been hearing is: "There's no problem. There are going to be thousands of jobs created in the community sector, and all the people who lose their jobs in the hospital system will be able to get a job in the community."
I think it's a little more complicated than that. I think there's going to have to be a lot of money spent on labour adjustment and on in-service training, and there will hopefully be people, with some dollars, able to take retirement, and all those types of things that come into a labour adjustment policy.
I'm not entirely clear what your role is in that area and what the commitment is in terms of dollars. I think the dollars for labour adjustment are just as important as the capital dollars. My experience at Windsor was that the involvement of the labour community and labour adjustment dollars was one of the reasons the whole thing flew.
Dr Sinclair: That's a matter of concern to the commission as well. As you will see from our Thunder Bay report, we have asked the people on the ground, as it were, to develop a labour adjustment strategy, plan, and submit it to us, which we anticipate will identify the cost of labour adjustment. There's no doubt there will be costs of labour adjustment. The health services system is a very labour-intensive "industry." I hate that word, but that's what's it's referred to oftentimes.
The system is very labour intensive, and if it is to be restructured with a view to greater affordability, it is very probable there will be fewer people working in it in aggregate, or there will be people working in it for rates that are lower than the current rates. All labour is a question of rates and numbers.
We are anticipating, we are requesting, that every community affected by our restructuring exercise will develop a labour adjustment strategy; first of all to tell us how they propose to deal with the redistribution of labour within the remaining institutions in a fair and equitable way, and second, how they will deal with adjustments from whatever the current numbers are to the new numbers in such a way as to --
Mr Cooke: Where do we expect to find some dollars? Labour adjustment costs lots of dollars.
Dr Sinclair: They will be, in our view, part of the reinvestment cost of getting there. That's another form of capital investment, if it is on the early retirement side of the house. It's an operating dollar if it has to do with training. You're all more familiar with that than I, Mr Cooke.
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Mr Cooke: We weren't laying anybody off. This government is.
What kind of dollars? Do you have dollars in the health budget for labour adjustment, specifically in hospital restructuring? I mean, not little dollars.
Ms Mottershead: It's the same amount of dollars and approach used in Windsor; that is, the HSTAP program is the program the government has right now in terms of labour adjustment and training and retraining and job registry and trying to get people matched up to places where there is work. So far that's the only approach we have --
Mr Cooke: So there's nothing, because this is much more massive than --
Ms Mottershead: Well, one of the things we are looking at at JPPC, which is the joint policy and planning committee of the OHA and the ministry, is the one-time restructuring costs incurred in each hospital's budget and removing those from the budget in terms of doing the allocation for the next round of targeted reductions, so that in fact we don't have --
Mr Cooke: How much time do I have, Mr Chair?
The Chair: You've got about three minutes.
Mr Cooke: I don't want to spend much more time on this, because I do want to get to -- I'm not talking about layoffs and job loss from the $1.3 billion worth of cuts, because that's a different issue altogether. I'm talking about the cuts as a result of the restructuring process. Basically, what you're saying to me is that at this point there's not a separate strategy in place to deal with that.
Mr Mottershead: You asked about money and I said that there is right now only one pot of money. In a way, the $1.3-billion reduction and some of the efforts of the restructuring commission to effect the savings through rationalization and restructuring are in fact to ease the burden of the 18%. That's part and parcel of that consideration, because if in fact you can restructure some hospitals quickly to achieve, then you may not have to deal with the 18% over three years.
Mr Cooke: Let me just finish with this, because this is the thing that confuses me the most. Here we've restructured in Windsor and all the hospitals in Windsor have been hit with their cuts of the $1.3 billion. They are laying off people, saying this has nothing to do with restructuring and the reconfiguration of Windsor; this has to do with the $1.3 billion worth of cuts. Maybe, so that I can understand this, you can explain to me what the relationship is between the government's decision to cut $1.3 billion and the process you're going through, if there is any relationship at all.
Dr Sinclair: Mr Cooke, there's obviously a relationshi,p because the decision to cut $1.3 billion, as you put it, is an environmental condition. It's there. That was a decision. It's not taken by the commission by any manner of means. As I said to Mr Gravelle, it would have been far preferable, as far as I'm concerned, to have begun this process many years ago, and indeed we should have done it in good times rather than bad times. But that's an environmental condition we know is there. We're just working with that as best we can.
To continue very briefly --
Mr Cooke: Can I just -- the Chair is going to cut us off and I want to try to get a better understanding. When I say the relationship, yes, of course it's an environmental condition that you're operating under, but when the minister says $1.3 billion has been cut and the way that money is going to be found is through your commission -- he said that in the House -- that's where I'm wondering about the relationship. I don't see any relationship at all between what you're doing and how to achieve the $1.3 billion, because that's coming out whether you recommend the status quo or change.
Dr Sinclair: From our perspective, as I said, we do not have a target, we would not accept a target, except that there are environmental conditions determined by others, so that's the way it is. But in the past, cuts of all kinds have been taken from hospitals more or less across the board, so the profligate and the parsimonious and the efficient and the inefficient and the well endowed and the less well endowed have all been hit more or less the same. If that were to continue, I am -- and I'm speaking personally here -- quite convinced there would be substantial service losses and service disruptions that need not be. I believe there is sufficient money in the system to run a first-class, accessible health services system.
From our perspective, we started with hospitals in order that we could assist that sector to restructure and operate on a much more economical basis without having to resort to the across-the-boarding.
Mr Cooke: But it's the biggest cut of all time. The $1.3 billion is across the board.
Dr Sinclair: We're working as hard as we can to get restructuring decisions and related recommendations in place for the whole of the 220 public hospitals, approximately, in Ontario. Frankly, we can't get there in time to get it all done this year, although we still have our target to get hospital restructuring done in 18 months. But the quicker we're able to do it, we believe, the better the hospital sector will be able to deal with this environmental condition of minus $1.3 billion.
Mr E.J. Douglas Rollins (Quinte): Thanks, Dr Sinclair and Mr Rochon, for coming here. I think it's nice that we have the opportunity to dialogue with you people.
You said you had 18 months. You've already been at it now for --
Dr Sinclair: Seven.
Mr Rollins: So we've got roughly 11 months left.
Dr Sinclair: If I may, 18 months has been our self-imposed target for hospital restructuring. We have four years. I wish it were 18 months.
Mr Rollins: By that time, you will have visited basically all the hospital structures in Ontario that you will be looking at for restructuring?
Dr Sinclair: That remains our intention.
Mr Rollins: Okay. When those hospitals close and when you start to readjust those hospitals -- as you said before, you're going to put some people out into the extended care type of thing because it's going to burp out into those areas and put pressure on others. In those considerations of that hospital, are you still taking into consideration that bulge going out into the community in that decision-making that you're doing?
Dr Sinclair: Very much so.
Mr Rochon: In our work, one of the things we do is assess the reduction in acute care services in terms of length of stay and capacity and recommend investments in home care to deal with the bulge you refer to.
Mr Rollins: Are we setting some goals and some standards for days of stay in hospitals? Does that have some bearing on it, in that extended care thing?
Mr Rochon: Yes.
Mr Rollins: I think this is the one saving grace we have to look at, as people who have to go back to the public and get re-elected, that we have still got to be able to look after those people who are sick. They look at it as, is there a problem?
Mr Rochon: Mr Rollins, our approach in all of this is to preserve services. What we are establishing for the province is a series of, in part, performance benchmarks based on what the hospital industry tells us is achievable. We are, in our view, giving reasonable time frames for the hospital community to respond, to make change, and in my conversations with individuals in the hospital management in Ontario, they tell me that they believe they are achievable targets.
We consider the need for reinvestment in community services as a requirement. In our view, the ability for hospitals to restructure the way in which they provide services is contingent on appropriate investments in community services and extended care services and the like. Without it, we will not be able to achieve what we believe can be achieved.
Mr Morley Kells (Etobicoke-Lakeshore): May I echo my colleagues' thanks for your being here today. The preamble, from my point of view, is very simple. I was talking about the Queensway hospital, and I'd like to talk about it a bit.
We got into this conversation because the minister made it abundantly clear that the political ramifications of the potential closing of hospitals were not his at this time and had been moved over to your commission. He wanted to make the point that there was definitely, at this time, no relationship between his responsibilities as a minister and your responsibilities at the commission level. I said, that's fine, I think I understand that, but the political reality is that the folks out there don't understand that. When rumours start about hospital closings, people react and politicians are drawn in. As much as you are a non-political organization, there's a whole bunch of politics in what you're about. It makes it difficult for the public to understand and certainly makes it difficult for politicians to do their job.
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Having said all that, and in the same vein, I have a petition from my hospital -- I know we're not here to talk about petitions, but just so you get the feel for this -- caused by a rumour. A rumour got out there that a report was being sent over to you by the Ministry of Health that indicated that the Queensway hospital, which was not mentioned in the previous report when everything was looked at in Metro, was now on an endangered species list of I think 11 more. This caused a great deal of flurry, and when all was said and done, among other things, I had a petition signed by 20,541 people in a very short period of time. I know this doesn't do much for what you're doing, but I want you to understand that it does put a great deal of pressure on both the system and politicians.
Having said that, so I can better understand everything, is there a schedule to what you're about? If you're looking at the system right across Ontario, at what point in time does this big thing called Metro and all its hospitals and all the pressures here -- is this tomorrow? Could you give me some kind of time line? I get all sorts of calls: "When is this going to happen? What are they looking at?"
Mr Rochon: We will be able to talk about a schedule, we expect, within the next several weeks, particularly a schedule relating to large urban areas -- Metropolitan Toronto, Ottawa and London -- and we would be happy to share that with anyone who is interested.
I'd like to respond to your statement, Mr Kells, because part of the issue for us is the public perception that hospitals equal services. Adjusting or changing the roles of hospitals or closing them is different from access to services. In part, we are victims of our own debates in the past. What we're talking about when we speak to communities is the preservation of services. It may mean that the hospital you've been used to attending has a different role or, in the extreme, has been closed, and you might have to travel a bit farther to get the services you need. But we have to work at informing and helping the community understand that, and that's not only our role, that's the role of everyone sitting in this room.
Mr Kells: Now you're starting to sound like a politician and you're taking up a little of my time, which my colleagues are going to get after me over.
Mr Rochon: I'm not sure how to take that comment.
Mr Kells: Understand this. If I said that to the 20,541 people, they would just say: "So what? Leave my hospital alone," and I haven't yet said that. But let's go on a little further, because I'm going to run out of time.
I wonder, what are the criteria? If you had to say it in a minute and a half, when you look at a hospital, what are the criteria?
Mr Rochon: Quality, access and affordability.
Mr Kells: Yes, I wrote that down. And practicality was in there somewhere. You used that, Doctor.
Dr Sinclair: That has to do with the implementation of our decisions and recommendations on the basis of those three criteria. Absolutely. There's no point in having a criterion if it isn't a practical one.
Mr Kells: I've written that down. Having said that, according to the CEO at Queensway -- and I'm sure you'll be very familiar with all this because you're from Etobicoke in the last wee while -- he refers to the cost per weighted patient-day at Queensway and the fact that it's the lowest in Metropolitan Toronto. He thinks it's a very salient point. Where does that fall into your deliberations?
Mr Rochon: In my view, the affordability issue would look at the point this CEO of Queensway General made to you. But what we would look at is not only the cost, but the quality. If a hospital is providing services that could be improved by a larger critical mass, that would be an important issue for us as well. We don't look at these as a series of one-dimensional assessments. It's a mix of access, quality and affordability.
Mr Kells: Then if I assume that this large mass you're talking about is the rest of the hospitals around there -- I guess it's your previous hospital, Humber, and Northwestern and Etobicoke --
Mr Rochon: York-Finch.
Mr Kells: -- and York-Finch and Mississauga. How do we arrive at where my hospital, if I may refer to it as such, fits into that? How big is your blob going to be when you start looking at these masses? Are you taking Metro as a whole and you place Queensway in there, drop it in?
Mr Rochon: We would look at Metro as a whole, but we would also look at the surrounding communities around Metro. In fact, we've met with the hospitals and with the district health councils in the regions that surround Metropolitan Toronto, because we happen to have, in our view, rather arbitrary geopolitical boundaries that confound reasonable planning. It's not just a matter of looking at what this means for Metro Toronto, but it's also a matter of looking at what it means for Mississauga, Peel, Orangeville and all the surrounding communities.
Mr Kells: I understand that, because apparently roughly 25% of the Queensway's business comes from across the creek in Mississauga.
Staying on services and staying on neighbourhoods -- we have neighbourhoods, but, as you said, this funny little geographical boundary called "the creek" is a different neighbourhood, and they have a Mississauga hospital, which is rather huge, down the road. How does my little hospital fit in? How does it get any benefit for its neighbourhood values and the fact that it provides services on a broad scale? I still don't quite understand how that fits into the mass. In other words, how do you take my boundaries into consideration and services to that area and the past history of that rather large area having a hospital when you bring in Mississauga or you bring in Humber?
Mr Rochon: We have information that helps assess where patients go for services. For example, the number you just quoted is that 25% of the patients come from Mississauga. We can tell you how many patients from Etobicoke go to Mississauga, the reverse. We can assess the inflow and outflow of patients across the entire province to come to some determination about access and where people would go for specific services.
Mr Kells: My final question, then. Faced with all this, if I am sitting, as I'm about to be sitting, with the people in our community discussing Queensway in the future, what can a community do, given all the things you've just said? If I pulled it out of Hansard, which is not going to be difficult, and used that as my agenda for the meeting, my final question is, what could I tell them could be done if indeed we are in danger? I don't know; this was a rumour which has spawned a whole bunch of other problems. In general terms, what can communities do to stave off closings or cutbacks or whatever the terminology is?
Dr Sinclair: If I can volunteer an answer to that, I would give two pieces of advice. One is, don't pay attention to rumours. That's very good advice generally.
Mr Kells: I'll tell them that.
Dr Sinclair: The second relates also to Mr Rollins's question earlier. I would advise any institution, any organization providing health services, to get together with the neighbouring institutions and organizations involved with health services and see what makes sense from the point of view of providing, optimally, access to the people who need services, the highest possible quality of care, again bearing in mind the issues of critical mass that Mr Rochon referred to, and how can we do it most cheaply. Those are the issues.
If we had the platform of planning on a broader regional basis to go on, it would be terrific for the commission. As it stands at the moment, we don't have. We have almost community by community. The one regional plan we have is that for Metropolitan Toronto, but even that is very much limited by the artificial boundaries of Metropolitan Toronto relative to the 905-area communities.
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Mr Kells: I understand. Yes, we're going to try and do that, we're going to try and look at Etobicoke as a whole, even though that ignores some of these boundaries you're talking about.
There might be another problem, and I don't know whether there's an answer to it. In all the deliberations that have gone before, there's the politics of what hospitals are about themselves. If we're looking at areas as a whole and you have one hospital that appears isolated -- I'm not too sure whether that's a plus or a minus -- it might not appear in the delivery system that three or four together could do. You could have a hospital that almost sits out somewhat isolated; it might not get, if you will, enough value for what it can do because it's not in this so-called critical mass, which worries me a bit.
I'm talking about some past studies or reports that apparently have been done involving Humber and York-Finch and some of these other hospitals, and Queensway has not been drawn into that picture, if you will. I see that as a problem. I wonder how you address that.
Mr Rochon: I think part of it comes back to the point that Dr Sinclair made, that is, that it's incumbent on institutions to work with other organizations to make sure that doesn't happen. I have experience in working with Queensway on a number of issues, and I think that Queensway is part of an organization with other hospitals in the west end of Metro. The more we can encourage facilities to engage in those kinds of relationships, I think the better off we all will be.
Mr Kells: I'll end it with that. If I said that, it would be politics, though.
Mr Wayne Wettlaufer (Kitchener): Thank you, Dr Sinclair and Mr Rochon, for coming today. I'm very happy that you said the OHRC is committed to being practical in every area of the province and that our government's financial targets aren't influencing you in your decisions. However, I don't think that is guiding the district health councils. I know in our own area the district health council and the hospital task force seem to be guided only by the fact that they believe there will be an 18% cut in funding and their report is being based entirely on that scenario.
I'm not putting Mr Rochon on the spot here. I asked him about it prior to the hearing and he said, "Feel free to ask it here." One of the comments that was made by one of the local health professionals in our area is that Mark Rochon's sole raison d'être is to close hospitals. I know you want to comment on that. Would you comment on it now, please?
Mr Rochon: I think what we are called speaks to that question. In other words, we're health services restructuring, and part of our mandate is to make the hospital subsystem work better. Part of that means merging hospitals, part of it means changing clinical focus and programs, and part of it means, in some instances, closing facilities. We're much more than, as you referred to, an organization that's oriented only to closing hospitals. We're looking at the system as a whole, and as we move through communities we will be making a series of decisions and recommendations that will not only deal with hospitals but will deal with the broader health system.
Mr Wettlaufer: But how do we convince the district health council and the hospital task force, who are making their own report to the Health Services Restructuring Commission, to come up with a report that is not entirely based on the scenario of an 18% cut?
Mr Rochon: Part of it may be to deal with the issues from the perspective of the criteria we look at. They have to look at issues of quality and what that means; in terms of critical mass, the more you do, the better you are, those sorts of considerations; access, how far you have to go to obtain service and how quickly you can get it when you need it; and affordability. From our perspective, this has to be viewed as multidimensional. We're not just looking at one aspect of it. We have to look at all criteria.
Mr Wettlaufer: But these are very nebulous terms. Do we have any guidelines?
Mr Rochon: Yes, we do.
Dr Sinclair: If you were to refer to -- and I'm sure they wouldn't be documents unknown to the district health council -- our reports, our final report on Thunder Bay and our initial report on Sudbury, it was very clear in those reports that what we're dealing with there is not closing hospitals. We're dealing with the restructuring of the health services system. There is more to do beyond those initial reports, and we make that very clear. But if people can't take the message that we're concerned about dealing with more than minus 18% out of those reports, then clearly they're not reading those reports very carefully, and I believe most people are.
Mr Wettlaufer: Is the minus 18% a figure being used across the province, or is the minus 18% being used as an average around the province?
Mr Rochon: In my experience it has been a kind of mantra in the Ontario hospital system for the last several months and it's very hard to get people's minds off that, but that's certainly not a mantra among the members of the commission.
Mr Wettlaufer: I'm glad to hear that, because as a businessman I would have great difficulty with that.
One of the things that businesses look at whenever they are establishing in an area is the accessibility to hospital care, and there is some concern in many areas that merging of hospitals will have an effect on emergency care. How are you addressing that?
Mr Rochon: Again, this comes back to the question of accessibility. We understand that part of a vibrant economy is having reasonable health services. In communities like the ones we're focusing on, which are for the most part multi-hospital communities, accessibility is measured in minutes and we're talking about not significant distances. When we look at accessibility issues in communities like Kitchener-Waterloo and then talk to someone in northern Ontario about accessibility, we get a very different definition.
Mr Wettlaufer: I can appreciate that. The minister used a figure last week of 568 patient-days per 1,000 population as being a high measure of efficiency. I wonder what figure the restructuring commission is using.
Mr Rochon: That figure in terms of utilization rates per 1,000 population will vary across the province, depending on the age makeup of the population, in terms of the proportion of elderly to the rest of the population, and also based on the existing admission rates or utilization. So the bed days per 1,000 will vary. What will be relatively consistent is our benchmarks in terms of length of stay. That will be at the top 25% level across Ontario.
Mr Toby Barrett (Norfolk): My question also relates to what a community can do, or in this case what a rural, small-town southern Ontario area can expect. We've had a bit of a discussion of Windsor and Thunder Bay with respect to the criteria of quality and accessibility and affordability, and I wonder if you could perhaps give a thumbnail sketch or almost a case study of how the criteria apply to a rural southern Ontario area -- I understand you're already working on some of those areas -- the purpose being, what would an area like that expect, or what could they, following that, do to better prepare?
Mr Rochon: Certainly when we're talking about communities with a single hospital, the opportunities to restructure are very different from multi-hospital communities like Kitchener-Waterloo or Thunder Bay. Part of our approach -- and we haven't dealt with very many of those communities at this point; in fact, we have yet to release a report on a single-hospital community -- will likely be how those facilities relate to others in the system. What would be the relationship between a small facility of less than 50 beds -- I know it's not a good measure, but if we could use that just to give you a sense of size -- to the hospitals up the highway, and how would that relationship be improved if we had better communications systems for access to specialist services that would be available down the road but could be enhanced if we had better ways of transmitting diagnostic information to those specialists to help support general practitioners in these communities? That's sort of the approach we would likely begin to look at.
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Dr Sinclair: Also, Mr Barrett, hospital services, as you know, vary greatly, from those that really should be available very close to home and those that really can be available at some distance. It's fair to say that in small community hospitals, we're going to have to make some judgements about what category of hospital services lies in the close-to-home variety and what can be provided safely and effectively and at higher quality at some distance. As Mr Rochon said, we're not really talking here about buildings. What we're talking about is a collection of services, and they are vastly different. We will deal with those as issues of tradeoff.
We have not had to deal with those very directly in the larger urban communities with which we've been working to this point, but during the course of this next year, as we move our sights from the urban to the medium-sized and then smaller communities, we're going to have to deal with that. I suspect that what we will do -- and again I'm just speculating here -- is deal with the issue two ways: one is the categorization of hospital services, and second, the issue of communication, to which Mark Rochon referred. The technology now does make it possible for MRI services, for example, to be provided pretty evenly, provided we can get transmission of the data. There are limits, but those limits are dropping pretty quickly as fibre optics communication comes in. Laboratory results, for example, could be well provided to a regional collection of hospitals from single sites.
Mr Barrett: In the area I represent, the Haldimand-Norfolk region, there's Tillsonburg hospital, Norfolk General, West Haldimand and Hagersville and, for that matter, War Memorial in Dunnville. For specialist services, there's access to London, Brantford to some extent, and Hamilton, perhaps an hour or an hour-and-a-half drive for specialist services. The smaller hospitals that I mentioned are probably a half-hour apart. For example, with the smaller hospitals is there a specific criterion for the number of miles from emergency department to emergency department?
Mr Rochon: We haven't established our criteria. In part, it comes down to -- I mean, there are people who live in Ontario who have quite vast distances to travel to get to an emergency room or a hospital.
Mr Barrett: Yes, northern Ontario, and perhaps more access to air service than in southern Ontario.
Mr Rochon: Correct, but I think the issue is again one of balancing quality and access as well, and those become quite challenging judgements to make.
Mr Barrett: These hospitals relate to more than one district health council. Should these facilities themselves or the communities be -- I'm not suggesting an end run around the district health council, but should they also be a little more proactive rather than waiting for a study?
Mr Rochon: Absolutely. Our view is that if communities do this on their own and come up with their own reasonable solutions, we would be very pleased to support them in it. The issue you raise about district health councils not quite fitting in the logic of how services are provided in your community might beg the issue of how those district health councils could work together; as opposed to having separate studies in each one, have three or four of them come together to deal with services in their area.
Dr Sinclair: As I said to Mr Rollins previously, if we were to have a regionally based platform of effective planning for hospital restructuring and other elements of the health services restructuring for, say, southwestern Ontario or even a significant slice of southwestern Ontario, that would be wonderful, and the sooner people get at it in advance of our coming, that would be terrific.
The Chair: On that good note, Dr Sinclair, I want to thank you and Mr Rochon for coming before the committee. That concludes the time we have. Thank you very much for coming forward.
This also concludes, before anyone escapes, the Ministry of Health estimates. I would proceed to take the votes now.
I put before you votes 1401 to 1406. Carried? Carried.
Should the estimates be reported to the House? Agreed.
That concludes the Ministry of Health estimates. We meet next Tuesday to resume the estimates of the Ministry of Economic Development, Trade and Tourism. We stand adjourned till then.
The committee adjourned at 1706.