Assemblée législative de l'Ontario

MINISTRY OF HEALTH

CONTENTS

Tuesday 3 June 1997

Ministry of Health

Hon Mr Wilson

STANDING COMMITTEE ON ESTIMATES

Chair / Président: Kennedy, Gerard (York South / -Sud L)

Vice-Chair / Vice-Président: Bartolucci, Rick (Sudbury L)

Mr RickBartolucci (Sudbury L)

Mr MarcelBeaubien (Lambton PC)

Mr GillesBisson (Cochrane South / -Sud ND)

Mr Michael A. Brown (Algoma-Manitoulin L)

Mr John C. Cleary (Cornwall L)

Mr EdDoyle (Wentworth East / -Est PC)

Mr BillGrimmett (Muskoka-Georgian Bay

/ Muskoka-Baie-Georgienne PC)

Mr MorleyKells (Etobicoke-Lakeshore PC)

Mr GerardKennedy (York South / -Sud L)

Ms FrancesLankin (Beaches-Woodbine ND)

Mr TrevorPettit (Hamilton Mountain PC)

Mr FrankSheehan (Lincoln PC)

Mr BillVankoughnet (Frontenac-Addington PC)

Mr WayneWettlaufer (Kitchener PC)

Substitutions present /Membres remplaçants présents:

Mrs MarionBoyd (London Centre ND)

Mr JackCarroll (Chatham-Kent PC)

Mr BertJohnson (Perth PC)

Mr JohnO'Toole (Durham East / -Est PC)

Also taking part /Autre participant:

Mr Sean G. Conway (Renfrew North / -Nord L)

Clerk / Greffière: Ms Rosemarie Singh

Staff / Personnel: Mr Steve Poelking, research officer, Legislative Research Service

The committee met at 1601 in committee room 2.

MINISTRY OF HEALTH

The Vice-Chair (Mr Rick Bartolucci): I'd like to call this meeting to order, and first of all welcome you to this year's edition of the standing committee meetings on estimates.

I'd like to start by introducing the committee members very quickly, starting with the government side: Bill Grimmett, Marcel Beaubien, John O'Toole subbing in, Frank Sheehan, Bert Johnson subbing in, Trevor Pettit and Bill Vankoughnet; the official opposition: John Cleary, and Gerard Kennedy, who normally is the Chair of this committee, but because he is the Liberal critic for health care, he will be assuming that role during Health estimates; and of course Marion Boyd, who is the Health critic for the NDP.

I'd also like to introduce the legislative staff at this time. We have Rosemarie Singh, who is the committee clerk; Steve Poelking, the research officer; and Beth Grahame from Hansard.

The agenda is as follows. We will start with the minister's presentation for 30 minutes, then the official opposition will have 30 minutes, the third party will have 30 minutes and finally there will be the minister's response for 30 minutes.

At this point in time I'd like to introduce Jim Wilson, the Minister of Health, welcome him to the committee and ask him if he wishes to introduce his staff. Minister, you have from now until 4:33.

Hon Jim Wilson (Minister of Health): Thank you, Mr Chairman, and members of the committee. I am pleased to appear before you again this year to review the estimates for 1997-98. I have with me today the Deputy Minister of Health, Mrs Margaret Mottershead.

I am grateful for the opportunity to discuss the achievements of the Ministry of Health and our government in health care over the past two years and our direction for the coming years. We are here to put the needs of the patients and clients first, the needs of people who need care in our system not just today but tomorrow and in the future.

Copies of my remarks are currently coming off the photocopier and will be available to members.

To meet patients' needs we must ensure that our health care system adapts successfully to the changing needs of a growing and aging population. We must ensure that we continue to provide the resources to do what is necessary to provide care. The challenges facing the health care system in Canada are considerable. Our population is aging, and as it ages, patients' needs change and the demands put on the health care system change.

Developments of new technologies continue at an astonishing pace. New procedures and treatments are being introduced, it seems, almost on a daily basis. What was considered ground-breaking medical treatment a generation ago is now obsolete medical treatment; diagnostic procedures that were state of the art a decade ago are now commonplace. Through medical advances, new drugs and technology, people are spending less time in hospitals and are recovering at home and receiving services in the community. Our health care system has to reflect these changes.

As the system adapts to changes, so too must governments. The government's role in the system is to ensure that the needs of patients and clients are met with a quality health care system. Our job is to provide a high-quality health care system to the people of this province and to be part of Canada's national medicare system.

For the first time in a very long time, our government is putting the needs of patients first to ensure that they get the right care at the right time in the right place, now and in the future. Our government's vision for health care is truly an integrated health care system -- that's the direction in which we're going -- one in which everyone from doctors to nurses to hospitals to other health care providers are working together to provide services where and when you need them. To make this plan a reality, we are renewing and improving Ontario's health care system now.

I am proud to report that we continue to lead the country on per capita spending. Ontario spends, on average, almost 20% more per capita on health care than any other jurisdiction in Canada. In the most recent budget, health care spending rose another $400 million dollars, from our campaign commitment of $17.5 billion to a record $17.8 billion, the highest amount ever spent on health care in this province.

Beyond the record-level program spending, we are also providing over $2 billion dollars to assist hospitals with the cost of changes such as severance, labour adjustment, job retraining and education, capital and other costs. This increase in funding is despite the $2.1-billion in reductions in health care transfers from the federal Liberal government.

Money issues are always at the centre of a discussion of health care, but there is a consensus within the health care system that the amount of money being spent on health care is sufficient to meet the needs of the patients and maintain a high-quality, accessible system. I'm pleased to say that those sentiments about spending enough money on health care were echoed in my office just two weeks ago by the Ontario Nurses' Association, who made it very clear that we're spending enough on health care; we just have to get our spending right and get our resources directed to the patients and the front-line providers.

For example, in the Toronto Star last December, Professor Greg Stoddart

of McMaster University said, "We are not using the money we have in the system as well as we could."

In its pre-budget submission, the United Senior Citizens of Ontario put it this way: "We feel there is enough money being spent on health care in this province, but it is not being spent efficiently."

Yet another observer of public policy said: "I am convinced that there is enough money in the health system. I don't think we are spending it as effectively as we can." That last statement was made in September by Dalton McGuinty, the current leader of the Liberal Party of Ontario.

There is consensus that we are spending enough, but are we getting the most services for patients and clients that we can? Restructuring our health care system means making it better so patients have more and improved services, modern full-service hospitals with the newest technologies, drugs and treatments.

Changing the system is critical if we are to invest in new programs and services for patients. We need to move away from bricks and mortar, remove the duplication and inefficiency in our system and reinvest these savings into services for patients. To do otherwise is to continue to spend money on programs, facilities, services and systems that are outdated, while the needs of patients grow.

Our vision for health care is to ensure that patients receive the treatment they need, when and where they need it. Our vision calls for meeting needs of patients in the community and in institutions; to work cooperatively with providers to bring in reforms, to reinvest in priority areas, to expand treatments in cancer treatment, dialysis, cardiac care, community mental health and many others.

Of all the changes under way in the health care system, the most important is that of the Health Services Restructuring Commission. If there is one frustration with the restructuring commission, it is that it was not established 20 years ago. The commission is widely recognized within the health care system, and its work is not always pleasant, but it is extremely necessary and long overdue.

I agree with Tom Closson, the president of Sunnybrook Health Science Centre, when he said in a Toronto Star article last December: "Look at how much money is spent on hospitals and how practices have changed over the last 10 years and yet we still have the same number of physical buildings open in this province."

In fact, we have about the same number of physical hospital buildings in Ontario that we did 20 years ago. The need for change is recognized universally, and Ontario is the last province in Canada to make those changes.

All of the restructuring projects included extensive consultation with hospital and communities across Ontario. I think this is a tribute to all of the district health councils, and this level of consultation is widely acknowledged in the communities where restructuring is taking place. For example, an editorial in the December 14 issue of the St Catharines Standard said this about the DHC's preliminary restructuring report for the Niagara Region:

"It is important to recognize that the controversial report was not drawn up by bureaucrats whose vision is blurred by the Toronto skyline, but by local people who share the concerns of their families, friends and neighbours in the villages, towns and cities which make up Niagara. The report was destined to be controversial; it will be praised and condemned but it is made in Niagara for Niagara."

1610

The time is past for discussing the restructuring of our hospital system. Clearly we have to get on with the job. We have to do this, because between 1989 and 1995 more than 11,000 hospital beds -- the equivalent of about 40 midsized hospitals -- were closed, yet no hospital buildings were closed in this province.

The problems of duplication, excessive administration, overlap and overcapacity were left untouched at the same time that waiting lists for procedures were growing. It is not logical, responsible or compassionate to pour money into bricks and mortar and administration when people are going without care.

Bricks and mortar do not cure patients. The quality of health care in Ontario, the accessibility of services, is not determined by a street address or a postal code. Buildings do not provide the care. Health care is provided by caregivers. In Ontario we are blessed in having some of the best in the world at all levels of the system.

We must listen to those caregivers like Dr Wilbert Keon, director of the University of Ottawa Heart Institute, who said in a submission to the restructuring commission: "Halfway measures will not solve the problem, we must be decisive and we must act now. If not, everyone, particularly the public, will lose"; or Krystyna Gibson, a medical technologist at Grace Hospital in Ottawa who, in a letter to the Ottawa Citizen said, "The reason for restructuring is to preserve health services, not downsize"; or Dr John Malloy, the head of Sudbury Memorial's emergency ward, who said about the restructuring plan in his community: "Someone has finally had the courage to bring some common sense, some economic sensibility to a rather chaotic situation. In my view the patients are going to be the winners in this."

To appreciate where Dr Malloy is coming from, it is worth mentioning that in Sudbury there are currently two emergency wards treating about 90,000 cases per year. Last year, 3,800 patients were transferred by ambulance from one hospital to another for tests or treatment -- in fact, they were spending about $1 million a year on the shuttle bus between buildings -- an average of more than 10 patients per day shuffled around three different buildings. The new single emergency ward in Sudbury is designed to handle 93,500 cases per year -- an increase of 3,500 cases, all in one building, all under one roof. Everybody can park in the same parking lot. Doctors won't have to decide in which parking lot they start off in the morning and end up in at night. By restructuring the hospital system and reducing the number of hospital buildings, we can improve the quality of care and reinvest these savings into our health care system.

Sudbury is only one example of where we're having fewer but improved hospitals and where we can improve care. In a letter to the Windsor Star on December 17, John Finncy, the director of public relations at Windsor Regional Hospital, wrote, "Although beds have been closed, Windsor Regional Hospital is caring for more patients today than we did five years ago."

That is the critical point of the restructuring process. It is possible to provide better hospital care than what we are currently providing, while preparing for the needs of all Ontarians, including an aging and growing population.

That is the experience in Winnipeg, where the Centre for Health Policy and Evaluation studied the impact of downsizing hospitals in Manitoba. We didn't do this last year, but I'd like to table that report with the committee. You only have to read four pages to have your mind completely blown with respect to the efficiencies they found. These were academics looking for trouble, they couldn't find the trouble and in fact found things had improved dramatically as a result of restructuring. The report concluded that access to hospital services improved by restructuring and that the quality of services remained unchanged; nursing care per patient went up; the number of hip replacements, cataract and other surgeries went up, some by as much as 33%.

I am confident that with the expertise of our health care providers and administrators, we in Ontario will at least meet, if not exceed, the level of service improvements realized in Winnipeg and other cities in Canada that have already gone through similar restructuring exercises.

When I spoke with you last year, I said the reason restructuring had not taken place 10 or 15 years ago was politics. That is why we established a non-partisan, arm's-length commission to oversee this process.

It remains this government's intention to continue with this process in a non-partisan manner without interference from any political party, including my own. I appreciate that political pressures can be overwhelming, but if we are to meet the challenges of putting patients first, today and into the next century, we must be resolute and let the commission do its job.

The process of restructuring and reformation of our health care system is one in which all three parties have been deeply involved during their time in government. It is my view that the time is long past for us as legislators to show the courage that is being demanded of us to do the job recognized as necessary in this province over 20 years ago. The needs of the patients demand no less.

I do understand that it is difficult for some to accept that our system can be better with fewer hospital buildings. In my community and communities across this province, the local hospitals are more than just buildings. They are where we are born, where we are treated and where loved ones died.

But if there is one aspect to the controversy surrounding hospital restructuring that is most troubling, it is the response of certain union leaders to the fact that some of their members face displacement or job loss. This is an unfortunate reality of the restructuring process, and not one that we take lightly.

I have sympathy for individuals who may lose their jobs, but the system will create new jobs for which former hospital employees will be eminently qualified. Community-based services need the expertise of those who worked in hospitals. While I have sympathy for individuals who are displaced, I will have no truck or trade with those union bosses who are bitterly fighting to preserve the status quo. By doing so, they are putting their own narrow self-interest ahead of people who need care.

Let's put in context what some hospital leaders want. They would prefer that taxpayers pay for bloated organizations and bureaucracies that are providing overlapping and duplicate services, instead of enhancing the access of health care to the people of this province. They would prefer this to freeing up money to put into more services and better health care for the people of this province.

How could any Minister of Health in good conscience keep the status quo, when at the same time Ontarians' need for health care is growing? Yet that is precisely what union bosses are demanding I do. Theirs is a request that I will not fulfil.

To those who may be displaced, understand that the system is changing and that the priority is patient care. Let me also say that every dollar and more saved by this restructuring is being reinvested into the health care system. The new services provided through these reinvestments create new jobs for health sector workers. So far, we have invested almost $1 billion in savings in health care. These reinvestments put the patient first. They shorten waiting lists and travel time for patients out of town.

In the area of cardiac care alone, this year we have made an additional $35-million commitment to reduce heart surgery waiting lists, the largest reinvestment in cardiac care in this province's history. When we made that reinvestment, Dr David Naylor, from the Institute for Clinical Evaluative Sciences, predicted: "These funds will shrink the queue to its shortest period ever. This is a very important major step forward."

Even before that reinvestment, we were already experiencing an increase in the provision of cardiac services in Ontario. The March issue of the Cardiac Care Network communiqué reported that the number of cardiac surgeries provided to Ontario residents was 38% greater in March 1997 than in March 1996. That had much to do with the $8-million investment we made just prior to that time. The number of cases for the full fiscal year 1996-97 was 10% greater than for the year prior.

It is this government's commitment to provide the funds necessary to introduce new programs and to further reduce waiting lists for cardiac care and other critical services. It is my privilege as Minister of Health to make these reinvestments into new programs. For the front-line workers, these reinvestments in our system mean they can provide better care to their patients. For the patients, it means better treatment.

For example, when we announced we would spend $18.9 million for a new cancer treatment centre in Windsor, Ethan Laukkanen, CEO of the Windsor Regional Cancer Centre, said: "This was absolutely critical. This will enable us to treat people near their home."

The Windsor Regional Cancer Centre is part of a larger cancer treatment commitment undertaken by this government, which includes an additional $24 million for improved breast cancer screening and an additional $16.5 million for improved cancer care, including Taxol and other drugs to help fight breast cancer.

1620

This year the Premier and I announced the establishment of Cancer Care Ontario, a new agency that will link and integrate cancer services throughout Ontario. This will permit us to provide better services closer to home for people who need care. That's putting the patients first.

Unlike previous governments, much of the almost $1 billion in reinvestments in our health care system came from within the health care budget envelope. It is possible through more efficient use of our health care dollars to provide better services, more accessible services and improve patient care.

We are in the second year of our $170-million reinvestment in community-based long-term-care services such as nursing, personal care, homemaking, meal programs, attendant care services and therapies such as speech-language pathology, physiotherapy and occupational therapy.

This year we reinvested $57.2 million to acknowledge population growth and the special circumstances of northern hospitals, $14 million of which is specifically earmarked for northern Ontario. This is in addition to the $25 million invested last year into 18 hospitals in high-growth areas to help them deal with the pressures of a growing population.

We have reinvested $23.5 million into community-based mental health services to treat people with severe mental illness and to build up community support for people to return home and function in their community. We've expanded dialysis services across Ontario, allowing kidney patients to receive treatment closer to home, by reinvesting -- it's not $25 million; the total is $36 million.

These are just a few of the close to $1 billion in reinvestment in providing more health care services to the people of Ontario. I'm proud to say that these reinvestments are already achieving our goal: increasing the number of services delivered to patients and clients in this province.

For instance, in 1994-95, the number of Ontario residents receiving cancer care was 82,864. This year's numbers are projected to be well over 100,000. This number outstrips by half the number of new cases expected in a year.

The number of MRIs done in Ontario last year was 19,000. Compare that to 1994-95, when the total was just around 12,000. With our commitment to triple the number of MRIs, the projected number for this year will increase to about 20,000.

The number of bone marrow transplants has almost doubled in the province since 1994-95, with a projected number this year of 507.

There's more. Our $170-million reinvestment into community-based long-term care is going out to people of all ages across the province who want and need to receive care in their own homes, schools and communities. Already, more than 200 community groups that support people living in their own communities have received more than the $130 million I've announced to date.

Since 1994, nursing visits have gone from 5.9 million visits to 7.3 million visits. This is a 23% increase and it translates into 1.4 million more visits provided to patients, far outstripping the growth in population.

Our reinvestment of $23.5 million into community-based mental health services has resulted in an additional 164 programs. That's on top of the 300 programs already funded by the ministry at the community level. Yet we clearly realize the need for institutional services for people with mental health problems, as our reinvestment of $18 million into that side of the ledger illustrates.

More people are now receiving dialysis closer to their homes, making a profound difference in their quality of life as they struggle with kidney disease. Our reinvestment of $36 million has resulted in an additional 20 dialysis units, many of which are already up and running.

Finally, I'd like to mention the Ontario drug benefit program. We have added 465 new drugs to the formulary through a streamlined approvals process that gets patients the drugs they need in the most expedited system in the country. Our drug benefit program is the most comprehensive and by far the most generous in Canada. By the way, the 465 drugs is after about five years of the previous government almost completely freezing the formulary and delisting 260 drugs.

These reinvestments are only one part of our commitment to maintaining and improving health care services in Ontario. Funding the programs doesn't make much sense if we don't have trained caregivers in place to deliver the care. In this respect, I am pleased to discuss two current government initiatives: the new agreement with Ontario's doctors and our nurse practitioner legislation.

I believe the advancement of nurse practitioners will address two concerns. The first is the future of nursing as we rely less on hospitals. The role of nurses in the delivery of health care is growing. Our nurse practitioner legislation will allow nurses to achieve even greater importance in the system.

Secondly, nurse practitioners will also help in underserviced areas. In the words of Carol Sargo, the president of the Nurse Practitioners Association of Ontario, "A couple of nurse practitioners together with a family doctor in an underserviced area could beautifully service an entire population."

We responded to nurses who asked that we remove the red tape, allowing them to practise, to use the skills they have and practise to their full potential to better help patients across Ontario. This is a major milestone in recognizing the vital role nurses play in today's health care system.

I am particularly proud that it is this government that is finally moving on the nurse practitioner legislation. It is long overdue. Others announced it. It got tied up in review; we finally have legislation on the floor of the House.

When I spoke to this committee last year, we were about to enter negotiations with the Ontario Medical Association. As I noted at that time, for more than 10 years the relationship between various Ontario governments, regardless of their political stripe, and physicians has been unsatisfactory to both sides. Whether it was the extra-billing fight with the Liberals or the social contract dispute with the NDP, each government has had its history of poor relations with doctors. I also noted last year, and it goes without saying, that physicians are crucial to the health care system as a whole. As caregivers, they play a lead role. Despite media reports and opposition grandstanding to the contrary, our goal is to work cooperatively with the province's physicians.

That is what I said last fall. Today I'm here to say that after long and difficult negotiations, we have reached a three-year agreement with Ontario's doctors that I hope will put the years of stress and discord behind us. I am particularly proud of the agreement reached with the medical profession because it allows us to enter into a new, cooperative relationship with the medical profession and it holds the line on increasing medical costs.

In this agreement, there is no new money for higher physician fees. There is, however, an acknowledgment that increased population and demographic changes do increase demand on physician services. Therefore, we are prepared to put new money into the OHIP pool to pay for new physicians, new patients and the increased patients' needs created by an aging and growing population.

There is the possibility of a modest conditional fee increase in the third year of the agreement, if and only if physicians can save money within the system through modernization and tightening of the fee schedule and through utilization controls. There are no new clawbacks on physician incomes in this agreement. However, a 2.9% clawback will continue until next February to make up the social contract commitment of the medical profession. While I understand the 2.9% clawback was a major sticking point during negotiations, the government did not feel it could in good conscience absolve the medical profession from its social contract obligations when everyone else had met theirs.

The government also agreed to continue subsidizing malpractice insurance premiums, a practice that started over a decade ago and continued under governments formed by all three parties. However, we have instituted a joint ministry-Ontario Medical Association committee that has been charged with trying to find ways to reduce the cost of malpractice medical insurance, including seeking a new insurer. Because it is a three-year agreement, it offers some stability and a longer time frame for both sides to come together to collectively address the challenges facing the delivery of physician services.

Through the physician services committee, which is established under the agreement, and other liaison committees, the government and the medical profession will work together to reach solutions on the challenges facing our health care system. This new era of consultation with the medical profession is in keeping with our policy of consulting widely with our partners in the health care system. It is this consultative process that persuaded the government to delay the third-year funding reductions for hospitals. We believe that rescheduling this reduction will allow hospitals to better adapt to the changes without risking the quality of patient care. We listened to the hospitals' concerns and we have responded.

In the course of the last year there was a shift in the direction of Ontario's health care system. It was a change away from the time when the various components of the health care system operated independently and in isolation from each other. It was a change to an integrated health care system where the patient is the only priority.

For too long in this province and this country, the standard response to demands on our health care system was to spend more money. For too many years, health care spending in this province experienced double-digit increases annually, yet the system didn't work as a system and patients weren't always put first. Despite the calls from experts in the field as far back as the late 1970s, we are only now beginning to restructure the health care system and redirect money to where it is needed, that is, into front-line services for patients.

Our vision is that the needs of patients and clients come first. The expenditure of money is targeted at the patient or at our home care clients, not at the providers. That's called patient-based budgeting. It's what we promised in the Common Sense Revolution. In simple terms, it means putting the needs of the patient above the needs of hospital administrators, above the needs of doctors, union bosses and others in the health care system, including politicians.

We are moving into the new millennium. Until recently, our health care system was attempting to impose solutions of the 1900s on the problems of the 21st century. But new challenges call for new solutions, solutions which meet the needs of patients now and in the future. Our government is working with health care providers to find these solutions.

We have made the shift towards the future, and I believe the people of Ontario, and ultimately that means all of us, will be the better for it. Thank you for your patience.

The Vice-Chair: Thank you, Minister. I'd like to turn now to the official opposition, the Liberal critic, Gerard Kennedy, who has up to 30 minutes.

1630

Mr Gerard Kennedy (York South): It is a pleasure to attend the hearing today to have an opportunity to talk about the health system. It has been hard to come by in the normal course of events. I am certainly glad my Liberal colleagues agreed it is in the public interest that this ministry, above all, be examined by this committee. The profound changes that have taken place in the past time -- and I say "changes" advisedly, because too often that word is being utilized as a substitute for something good or an improvement -- the changes which have taken place under this government, have not been available to legislators of any party, have not been available to the public. Quite simply put, this lack of accessibility has itself been a cause of concern and consternation on the part of the public, because every area, every fundamental of health care, has been touched upon in the last year.

When we hear the minister speak before us today we're really called upon to note a couple of things. One is the very similarity to the words we heard last year at this committee, and also the absence of some of the fundamental questions which are being addressed by the ministry.

I'd like to lay out for you what I hope we will find in the course of these hearings, and I'm sure with the minister's fulsome cooperation, be able to discover what wasn't in the minister's remarks today, which is the interests of patients; where indeed the patients' interests will be expressed in the course of the ministry's attempts to change so much of what affects patients.

We look at the broad picture and the experience of patients today, people we have brought before the Legislature, in a different light for them. No matter how carefully we try to put it, there's a certain indignity to having your personal health situation brought forward and put forward to the public and to the media. It's something we do very carefully, but it's something that's done by the families themselves because of the experiences they've come to encounter with this changed health care system.

We spoke about people throughout the course of the last few months who have found, if not mismanagement of our health care system, then serious, serious questions about how it is being run. The experience and the cases that we've presented draw, I think, a certain light of tragedy, if not outright difficulty, with the statement on the part of the minister, to be found in the future vision statement of the ministry, that somehow patients are having access to the right care, at the right time, in the right place. Far too many Ontarians have found themselves in the wrong place at the wrong time, even though they believed that the place they went -- the hospital emergency room, the waiting list on the part of skilled doctors and other health care practitioners in this province -- was the place where they could receive the quality of care they'd become accustomed to in years past.

What we have seen in recent months is a pattern of patching, of little dollops of money given to this program or that program, sometimes to the outright confusion and perplexity of the communities affected. One hospital administrator was happy in one sense to have a dialysis unit but is running a deficit and didn't really want that dialysis unit, but because it fits the picture the government is trying to portray, it happened, it occurred.

We have a job to do in this committee. We have a job to do that is fairly fundamental: to fill in the gaps that have been, throughout these last two years, unavailable to members of the public. I know members of each party will use that opportunity to its full extent. We need to explore, for example, the feature of the past year that brought chaos to our hospitals, chaos brought on by a subject the minister did not even address in his remarks, which is the cuts to hospitals.

Every single member of the provincial Parliament in this room has had their hospitals cut those hospitals have been cut by an average of 12%. Those cuts have been random. There is a formula that after the fact tries to justify it, but it bears no relationship to the needs of patients. There is nothing in that formula that talks about how much patients need help; it only says, "If the minister determines he wants to extract money from hospitals to this extent this year, then here is the fairest way to deal with that."

The OHA, the OMA, the nurses, the head of the restructuring commission have all condemned the idea of these cuts taking place in advance of any plans. What we've had instead is 210 different decisions being made, sets of decisions about how to ration health care in this province, aided and abetted only by sets of formulas that are purveyed by ministry staff. The result of that has been the problems people have experienced in hospital. That has been the responsibility of this government in terms of what they have put forward this year.

It is our job in this committee to find out why those cuts have been persisted with in the face of mounting evidence, in the face of the problems, for example, of people like Mr Whitehill in Peterborough, in the hospital emergency room; Mr Wa-Il Akras at the Sick Kids emergency department; or the family of Leie Rykene in terms of wondering, as their physician wondered, as their specialist wondered, why it took days and days and days to get a bed for an angiogram and she died while waiting for it; and why referral hospitals for the 905 area are finding that they're not able to accommodate those referrals except with longer and longer waiting lists, leading to tragedies like the Rykene family's experience.

What we really need to know is, why would a government proceed with random cuts to hospitals when it had a study, as we introduced in the Legislature earlier this year, from the joint planning and priorities committee that it has with the Ontario Hospital Association, which said, with the most aggressive models possible, "You cannot do these cuts without taking away from patient care." Even in the little boxes they presented in their executive summary, which we have a copy of, they say how much hurt occurs, how much shortfall the government has had to inflict on the patients in this province, and it's substantial.

It's unfortunately expressed in dollars, something in the order of $300 million by the end of this year. Even with the most aggressive academic models, in some cases people would say the most questionable, pushing the limits, you cannot get the savings from the kind of marketing language which has been used by the minister today, which is "out of efficiencies and administration" and so forth. Instead, it has to come from the patients. It's too bad that study, like so many of the numbers we see flying around the health care system these days, can't be expressed in a better bottom line, the only bottom line which matters, which is the quality of life of people who find themselves in the misfortune of needing good health care.

We want to find out as well why hospital administrators are faced with additional problems in terms of the ministry. We want to know about some of the difficulties which were experienced in terms of hospital funding this year. There were at least three different sets of allocations, and we wonder why. Why were hospital administrators not allowed to know how much money they had to work with? In some cases, not until after the fiscal year had started did the restructured hospitals actually learn how much money they would have. There are hospital administrators worrying themselves to death about how they're going to be able to extract these cuts after the fact. This is part of the pattern of chaos that's been inflicted on this province's hospitals.

1640

The minister talks about and quotes in fact an administrator who says he's caring for more. They are indeed caring for more, but they're doing that with less money, fewer nurses and fewer resources. We would wish to have and we hope we will have later from the minister and from his staff some idea of how they think this is possible when already Ontario entered into some of this exercise with the lowest number of beds in the country. Many, many of those administrators, in their good faith and their effort to try and care for more with less money, have tried to do that, aren't succeeding and instead are finding themselves removing services. Rather than dilute the quality of some of the services they have, they've taken them away. So some hospitals now don't deliver babies any more and dump that on the system without any planning or arrangement.

We've heard I think a little bit today the case for a restructuring commission. What we hope to learn through the course of these discussions is something about the myths that the restructuring commission is based upon; the myth for example that there are 11,000 beds sitting there, drawing cobwebs, fully staffed by nurses, somehow draining the purse in terms of public expenditure and not making possible all the good things the minister talks about.

Instead, in most cases and in most hospitals across the province, those beds are filled with other services. They have moved in a way that this minister has not acknowledged to us today, but I'm sure will agree with when we come to more detailed discussions. They have made changes in medical management. They have created walk-in clinics. They have done day surgery. They have, in short, made use of that space.

It might surprise some members of this committee, and we'll see the minister perhaps confirm, that only a very small amount of the funds which the commission would extract on behalf of the government, which it would take away from hospitals, can actually be saved from the current number of empty beds. For example, you have communities like Toronto where most of the beds that we say are going to be closed, in other words not available and justifying the closure of 11 hospitals, have people in them today. These are beds which have people in them.

There aren't any T-shirts with nice sayings like "Right care, right place, right time." We don't often hear about "Quicker and sicker," because that's what the commission is doing and that's what we need to ask the minister. Why would we push medical management beyond what can be handled? Why are we requiring people to leave hospital quicker and sicker in a whole range of procedures without any corresponding community care being available to them? Why would we do that?

When we look at the kinds of strategies that have been put in place, we can't find people in that. I talked to the charge nurse in charge of obstetrics at a hospital, and they have the lowest ratio, at least one of the bottom two, in terms of how long mothers stay there after birth: 1.2 days. They did a satisfaction survey after doing this for a year, and what did they find? They found that the mothers hated it. They found that they felt like they were being forced out. They found that while they could afford to also give a phone call afterwards, in too many cases this added to a distressing circumstance. It was the lack of choice available to mothers in terms of that circumstance. All the post-partum treatments in the world don't work unless we have some recognition of that to begin with. So we find ourselves in those and other serious cases pushing people out of hospitals.

I talked to doctors in another community who told me about their chiefs of staff having to impose some pressure about how quickly to move people out of hospitals and how that's becoming an increasing phenomenon across the province. Unfortunately some of those cases have made their way to the Legislature as punch lines and tragedies for families.

The restructuring commission would tell us much, as the minister did today, about the empty beds, would talk to us about the idea that we've got too many hospitals. But we do not see from this restructuring commission -- we would hope to gain perhaps from the minister in the course of these discussions some idea of what will take their place.

We heard about the Niagara region report Made in Niagara. I can tell you that there are 7,000 people in Grimsby who don't hold that opinion. There are supporters of both hospitals in Niagara Falls who don't hold that opinion. There are people in St Catharines who don't hold that opinion, in Port Colborne and in Fort Erie who don't hold that opinion. Quite simply put, they don't recognize the formulas, the accountancy that is driving health care in Ontario today. They don't see that as being made in their home town.

What we have, and finally had recognition of -- and this is something we'll certainly want to pick up and receive the minister's further wisdom on -- is that the formulas for small and rural hospitals, two or three days ahead of the report for Lambton county, were suddenly found to be inappropriate; suddenly, like that. Can you imagine? Just 48 hours before the report was due the whole structure of hospital care in that province could have been changed for good, except suddenly somebody recognized that this shouldn't go ahead.

I would submit to you that we need some answers to questions if that's the kind of risk-taking that's going on on the part of the restructuring commission and when we're still unclear who is setting the policy, who is driving the truck here. Does the ministry abdicate all its policymaking or do we get some policy some times about some things? That's an important thing, as we look at the activity of this ministry for the year, for us to understand.

We understand too that there are -- inevitably, I would say to the minister -- people who will allege certain biases, certain preconceived notions on the part of the so-called independent commission. But certainly there are legitimate questions that have been raised. If we're supposed to have a community health care system, why are we instead authorizing mega-hospitals across the province? Why do we do that when in many cases -- in the case of Riverside compared to other Ottawa hospitals, in the case of Wellesley and Women's College, in the case of a number of hospitals -- those smaller, community-based hospitals actually can be more effective?

The other myth we keep hearing -- and I think it's important; if we are to discharge our responsibility, which is to explain to the province what's happening in the Ministry of Health, we've got to talk about the myth of bricks and mortar. The other day I delivered a brick on behalf of Doctors Hospital. They're quite prepared to give up their building, but they'll fight like mad to maintain their services, and that's what's threatened. That's what the restructuring commission would take away and give to a mega-hospital. They're prepared to do it for the same money, and yet the ministry, the commission, won't let them.

The bricks and mortar, the savings from closing buildings, will save us only 5% of the money that the restructuring commission is talking about taking away from the system; instead, the rest of that money is to be made up with the firing of health care workers, which make up the largest portion of the rest of the budget. Nurses and other health care practitioners will go, and the only basis under which they can be at liberty is if we push patients out quicker and sicker. It's the only way we can do it, and it's right there in the health commission's writings. But it's not what was talked about today, so it's hopefully something we're going to have some elucidation on from the minister.

We heard also about some of the things that are occurring with human resources. We have a new target in terms of health care. We have something called "union bosses," which I guess follows on the legislation today. It's unfortunate that we aren't in a position, through this committee, to look at the human resources factor and get some answers there. I hope we will be, but I wonder, given those comments.

Why have we laid off so many nurses? Why are we in the position now of losing other health care professionals without any kind of plan whatsoever to keep the best health care professionals that we have right here in this province? We have 24 hospitals headed for closing, and not one of them has a human resources plan, not one. I can tell you, in the case of Northwestern hospital in this city, where they're advancing the date to close it without even the go-ahead from the commission, that there are all kinds of people at loose ends, not knowing what's going to happen under that closing, and of course that lack of recognition is salt in that wound.

Somehow there has been a virtue put on change in the health care system for its own sake. But if we're really going to have change that equates to positive change, that actually meets some of the needs of patients, it's going to have to be measured again by how well we're able to get on side with that change the nurses, the doctors and the other people who are going to effect it. I hope we'll find out why that's completely missing from the strategies we've heard so far.

1650

Certainly we know there are gaping questions, and we know this will be the forum for us to deal with the change in at least one area of human resources, the deal with doctors. I guess this is a level where we could congratulate the minister for having solved all of the outstanding issues the doctors had with the ministry. The only qualification on that -- and I know the minister has heard me say this before -- is that all those issues the doctors had with the ministry were raised by the minister. So the various and sundry things he put to them -- the increased clawback on doctors, which was deducting from their income at the end of the year, the lowered ceilings, the liability insurance non-coverage that the minister proposed they should not get, the representation of the OMA -- all of those things have come round full circle and here they are in this agreement, to the satisfaction of the medical association.

We will want to congratulate the minister again when we discuss it in some detail and wonder if those large amounts of dollars which are available for that one part of the system are the beginning of a trend. Is the minister prepared to make those same kinds of guarantees to other parts of the system: three-year, secure, stable, increasing funding? Is that what we could look forward to, for example, on the part of some of the hospitals, some of the nurses?

We have had reference to nurse practitioner legislation. We hope the minister will be prepared to discuss the date on which the nurse practitioner legislation will be put forward to this House. There are more challenges for nurses than that legislation, but that legislation, which enjoys wide agreement, we certainly would like to see happen as the opening step.

When we talk about human resources and the role of the minister, we'll hopefully get to the whole notion of why the minister talks about a status quo that denies the substantial work that has been done on the part of nurses and doctors in this province already to deal with their limitations in terms of funds, to deal with the changes in technology, the aging of the population, on their own.

It is indeed unfortunate that their interventions about this have gone largely unresponded to; that rather than listen to the nurses and doctors when they say, "Too much too fast," their concerns are just papered over; that rather than have a forum through which they could participate -- we now have the beginning of some forum for doctors, which may head off some of the rancour and hostility that existed there. But we do not have a forum yet -- although I understand the ministry is latterly considering one -- to be able to bring in all these other professionals, because their voices are at odds with what we're hearing from the minister.

They have already made changes. They're not prepared to tell you, Minister, I don't think, that all those changes have been positive. They will no longer talk about optimum care for their patients; instead, they talk about what's realistically possible. Those are the terms you're setting them, and going beyond. You're asking those practitioners to go beyond even what's reasonably possible as you change the terms of reference, and yet these are the very same people whose jobs have been made increasingly difficult in many of the forums in which they work, who have been put the proposition that they're going to be the agents of change. It's not likely to happen and it's not likely to be successful unless -- perhaps we'll learn today some of the changes in policy.

We also need to look at what the reinvestment games have been like in this province. There has been a new sport, and it's called reinvestment. It's about the slow, slow use of dollars when you spend them and the very rapid cuts when you take them away. That has opened up a gap. We're looking forward to giving the minister the opportunity to close that gap, because it consists of his credibility and the credibility of the ministry in terms of whether they're able to provide the money to the people who need the services when they need it. I'll refrain from using the minister's slogan for that.

We know that last year, for example, in community mental health there was $25 million out of a $201-million budget that didn't get spent. It got announced, but it didn't get spent. That meant that even with some of the difficulties that were out there, not met by the community -- the minister did the official event and I did an unofficial one at different places; we visited around. I talked to many of the people who were receiving the largess. The only difficulty when the announcements about reinvestments were made this year is that quite a number of those had been announced before -- 12 months before, eight months before -- but they didn't get any money.

We have to get to the bottom of the reinvestment games. I'll just give you a quote, Minister, for you to be able to be prepared. One of your new commissioners to the Health Services Restructuring Commission, someone with a business background, I put to him the question -- and this is on the record of the review committee for new appointees -- what did he see as a reinvestment; is it when you talk about the money or is it when you spend it? He said it's when you spend it. That's what we have to look at, because there's a very large gap there as we search for the lost restructuring dollars, where they're going to be.

We talked about it last year: a $45-million increase in the Trillium drug program. If you turn to a certain page -- I think it's page 93 -- you'll find that we only spent $18 million. Where was that large increase? It's supposed to be $75 million in total, and we have projected expenditures of $18 million. There is a gap there. It would not be so serious if it was just a matter of numbers; it's not, it's a matter of people's lives, it's a matter of the patients' quality of life. That's what's being arbitrated by the numbers in this book, and that's where hopefully we're going to be able to be of some significant public value in getting to the bottom of it.

We'll go through the reinvestments. We talked about the cardiac surgeons. There was a big rush to use money in March. We saw the letter to the editor that said: "Look, why are you giving us all this money in March? The operating theatres are already overbooked." Again, we come back to a game, and that game just isn't funny. It's not about making the government look good; it's about managing this system with some care, some planning and an outlook that gives confidence. In addition to health care, we want to see what the minister's plans are to sustain confidence on the part of the public, on the part of the people who are affected in the system.

There's growing apprehension out there. Minister, you would be giving us too much credit should you believe that is manufactured by anybody in the province, the opposition or otherwise. Many of your federal colleagues, of whichever persuasion, found it at the doors during the election, that health care is an abiding issue in this province, and it is built upon the experiences people are having with your system.

One of the things that would allay some of those concerns, that would have people maybe not pay so much attention to the situations of the Ed Whitehills in Peterborough, the Leie Rykenes in York region, the others who've experienced tragedy at the hands of the system and the deterioration in the system, would be if there was a plan.

Minister, you didn't spend very much time today talking to us about integrated health. You didn't spend very much time telling us when we could expect some way to stitch together all these patchwork decisions that have taken place in the course of the last number of months. We have not heard about how we're going to be able to put together any kind of system that would respond to the needs of patients. Right now, patients are being left entirely out in the cold. Minister, if you intend to restrict patients' choices to a single doctor, if you intend to roster them, it's time to start talking to them, it's time to start letting the members of the public know that.

Yet we look at your figures this year, Minister, and we don't see the provision for that. We see arrangements for financing of doctors which, subject to the deal we understand has been ratified, suggests there will be no encouragement for primary care reform, because exactly the same dollars that are being paid through OHIP are going to stay there and there will not be those dollars available to effect any kind of transition on the part of physicians to a different kind of alternate payment plan.

We wonder where the impetus for reform has gone, Minister. We've been hearing week after week, month after month that something would be coming forward. As we harken back to some of the other things that have been mentioned, the community hospitals, the ones with the closest connections to the community, the ones which have established painstaking links with community health services, with the people who have been unaffiliated -- when you talk to Doctors Hospital, if you want to talk to their patients, you've got to speak in about 20 languages. These well-meaning practitioners of health don't believe it can be sustained in a mega-hospital. They think the hospital you want to send them to is great for heart surgery. They don't want to be there for primary care, for the kind of basic acute care that those hard-to-serve populations wouldn't get if it wasn't for their existence.

Minister, we don't have an explanation as to why a ministry that has talked for years about some level of community care has suddenly switched over to corporate care. That's what we have instead: very large hospitals aggregating services in a way that is happening in the only other place that we know, which is the United States. We have the belief now, I think, for a lot of people that we're headed that way, that we're going to have a two-tier health care system and it's going to be not just the result of the degradation of the system, which a lot of people are starting to find is problematic, but a result of some deliberate plan that's been developed.

And so it's incumbent, if we look at this, the largest single expenditure of the government, we need to know, does the minister have a plan? Is there indeed a plan for changing this health care system, or are we making this up as we go along, each area, time and time over? And certainly we look at the doctors' deal and we see the questions that raised.

So, Minister, we look forward to this discussion with you. We look forward to being able to ask the questions that have been difficult to do in the past, but more than that, we look forward to your answers.

The Vice-Chair: Thank you very much, Mr Kennedy. Now I'd like to go to the third party. Mrs Boyd.

1700

Mrs Marion Boyd (London Centre): I was struck, Minister, when you were doing your speech that in the first few pages the speech could have been given by any one of us in the Legislature. I don't believe there are any of us who don't believe that we need change and that we need fairly radical change in the way we deliver health care. I think we know that the changes that have happened in terms of the available technology, in terms of the kinds of skills we have, in terms of the things we've learned over the last few years at an ever-increasing rate tell us that our vision of health care, which for the most part really began in the 1950s to 1970s in this province, isn't adequate any more.

I must say that I wish you would try not to try and portray those who have questions about the way restructuring our health system is happening as wanting to protect the status quo, because I don't believe that's true and I believe what it does is make it difficult for us to have the kind of overall dialogue that we need to have in order to make this restructuring really work to take us into the next century. I believe that's what you want to do, I know it is what our party wants to do, and I think it is what all those working in the health professions want to do. The issue is not whether that's a good thing; the issue is how we do it, and how we do it in such a way that we're all working together instead of working against each other. I think that really is the issue.

The estimates discussion gives us an opportunity to look in detail at how the dollars and cents relate to the rhetoric and, may I say, the dream, because the dream is not something that I would necessarily disagree with.

I don't believe at all that we can afford, as you suggest of those who are critical of the way this change is happening, to continue to deliver health care in the way that we have in the past. I don't believe we can afford to keep open every building that we may have needed at a particular time, and I've never advocated that. I am fortunate that I come from a community that has worked very hard to try to come to grips with this kind of change and the changes that have happened in the willingness of those partners to sit down and actually talk together. I've had the opportunity of participating in over the last five years, and it's really quite a remarkable change.

When I was first elected and first was invited to visit with what was then the teaching hospitals' council in the city of London, I can tell you these folks were very, very far apart. They were very turf-conscious. They were finding it absolutely unbelievable that they might be asked to look at a delivery of health care that required them to shift some of their expertise into another institution, or indeed to look at a whole new mission. I don't think there's any question about that.

I've watched those folks work together and I've helped them work together so that we're much further along. We still have lots of difficulties, but people look at the London situation, look at the massive change that the restructuring commission suggested, and say, "Why isn't there the controversy in London that there is in Renfrew or that there is in Sudbury or that is looming on the horizon in Cornwall and other places?" I think the answer to that is that we all believe, health care professionals and politicians in our area, that we need to take this change, that this change will be good for us all, but that we must do it in a way that is truly cooperative.

So when I criticize in terms of how the restructuring is going, I criticize based on things that I think are going to obstruct the willingness to change that is there in some communities and that we want to foster in other communities. When people are facing massive change, when they are being asked to change the way they've always been taught to look at service delivery, it's very difficult. The more pressure that's on them and the more they see that as having little to do with their needs and everything to do with the financial bottom line, the more resistance and criticism you get.

It seems to me that one of the real issues for a lot of people is that they have seen this process as being driven by dollars and cents rather than patient care. I take very seriously that your ministry and you and health care providers who are engaged in this restructuring want this to be focused on patient care, but I can tell you that it is not the perception out there. As long as the perception is that all we're trying to do is save money, that we're not in fact trying to spend that money, as you suggest in your speech, in a way that gives more wisdom and gets us more value for those dollars, we're going to have a hard time persuading people to make the changes that have to be made.

Other jurisdictions have found this. When this kind of change is driven by competition, when this kind of change is driven by cost-saving as opposed to a real vision of how you can alter patient care to be more productive for both the person who is receiving that care and the community that cares for them, we know from experience that there's a problem.

I'll admit there is also a problem of galvanizing people to make that kind of change. I am one who knows and believes very strongly that when we are facing a period of financial difficulty, it does tend to focus people's minds a little bit more on how they can do things more efficiently. I don't think there's any question about that. I can tell you that had the grants continued to increase at 11% and 12%, as they had for the five years previous to the time we came into government, my community certainly would not have changed in the dramatic way it has, and I believe that a lot of others wouldn't. It is hard to get people to focus on that kind of massive change, particularly when we all tend to say, "Well, we've always done it this way and therefore we have to continue to do it."

So while on one hand I will say it is an impetus to change that we are faced with the real challenge of maintaining a universally accessible health care system, publicly funded and publicly run, at a time when certainly the resources that had been being absorbed by that system were far outstripping our ability to pay for it, we simply must go about our business in a way that convinces people that the focus is on improvement in care, and I don't think that's always been the case.

I do wish people would sit down and read some of the restructuring commission reports. I think some of them -- there's a huge difference in quality and in the way in which recommendations come forward and the conclusions that are reached depending on the communities, but I think it would give people more comfort. But I think the criticism of the restructuring commission that they have been far too bureaucratic in terms of looking at particular formulae as opposed to looking at whether those formulae in fact apply continues to be a problem.

1710

I believe that, with the exception of the mental health issues in my community, the recommendations of the restructuring commission are going to give us a much stronger, more compassionate, more effective and more efficient delivery of services. I really believe that. That doesn't mean it isn't painful for me to know that the hospital that has served three generations of my family is not going to be an acute care hospital any longer. It doesn't mean that the pain to those who have been served by the Women's Christian Association that runs Parkwood is any less than any other hospital that has been ordered to divest itself to another institution. The pain is there and it's very real and we're trying to cope with it in our community.

It doesn't mean that the pain for St Joseph's Health Centre of changing its mission quite substantially into an area that, although it was engaged in it -- it was engaged in geriatric and long-term care; it was engaged in ambulatory care. But it certainly did not see itself as being engaged in long-term chronic mental health situations, nor did it see itself as not having a function in terms of acute care. But those changes in mission they're prepared to accept, and they're prepared to see that the kind of caring they have offered is particularly suited to the mission that the restructuring commission has given them.

I think where that kind of interaction and that good faith is there at the table and people really are working together in the hospital sector, we can move along.

We still have the challenge of human resources. I would say to you very strongly, I really don't think it's helpful to attack union bosses when you know they are required by law to represent the interests of their members. They are required by our labour law to try and protect the jobs of their members and to do that to the best of their ability. It is not particularly helpful to assume that means they necessarily want only the status quo. Their words may say that sometimes but they're based on a lot of fear that their members will lose their livelihood.

You say in your speech, and it's quite true, that we are going to need to have these health care professionals in a different mode of offering their services. It simply is incredible to me that if you want to galvanize this kind of change within the health care professions you would have, first of all, taken away the clearinghouse for that in terms of HSTAP, and that you would not have made the very strong effort that frankly the restructuring commission did in ordering communities to set up human resources restructuring commissions to really look at how that works, rather than taking the combative kind of position you have.

I realize the legislation that was introduced today is not your legislation, but you're a member of a cabinet that has brought forward an extraordinarily inflammatory piece of legislation which is guaranteed, absolutely guaranteed, to make what you want to accomplish in terms of health care delivery extraordinarily difficult.

I would have thought, Minister, that you would have learned last year, when you took away the support for malpractice insurance with the doctors, when you stepped away from the table and told them you would only negotiate with individual physicians, took away all of the joint kind of actions that had been there by agreement with the OMA -- and as my colleague says, you have had to go full circle -- that you would have learned that confrontation does not get you the kind of change you want.

I think it's extraordinarily unfortunate that we're faced, at a time when had the effort been made to try and work the human resource issues through in a way that guaranteed -- and we could do that, because we need those health care workers -- jobs would be there for them and that if they needed to be retrained for those they would be retrained for them -- that's all that was needed. Yes, bargaining rights are an issue, but they can usually be resolved if the people who are the prime concern of unions are looked after and you don't see the kind of drain away and deskilling and disposable labour that seems to be happening in terms of the health care professions right now.

When we look at estimates we get a chance to really test out what is rhetoric and what is real. My friend the member for York South talked about some of the reality between what you have spent and what you have not spent. Unless things have changed remarkably since I was a minister and doing estimates, these interim actuals that we're looking at, and contrasting to the estimates for last year and the actuals for 1995-96 and looking at those in terms of what's happening in 1997-98, paint a very different picture than you've been talking about.

I think you do want an integrated health care system, but I can tell you that when you look at an estimate for institutional health care that was $7,480,753,400 and you see an interim actual that is some $545,000,000 higher and you look at health insurance, essentially doctors, where the estimates said $5,861,371,700 and it's up at over $6 billion, for a change of $141 million, and then you look at the population in health and community services and you see a huge underspending from the estimates, and the same in mental health, and the same in long-term care, these estimates tell a story about the silos still being very much there in terms of health care and the powerful players, the OHA and the OMA, still being the gatekeepers of the system.

When you talk about increases in your budget, increases in your estimates, we're going to be asking you to compare those to what you actually spent in 1995-96. You need to know that when your interim actuals in 1996-97 are $380 million more than your estimates, then that is a question. Where is it going? You told us in the Legislature that some $300 million was going to the doctors. That doesn't tell me about an integrated health care system, when we see thousands of others in the health care professions losing their jobs, when we see community health, long-term care being underspent to the extent that it is. These are the kinds of questions that we'll be asking, and we'll be pointing out to you that your interim actuals for 1996-97 are some $94 million higher than your estimates for 1997-98. So that means nearly $100 million are going to have to come out, even though you say you're giving more money. That's a problem for you and it's going to be a hard one for you to explain to people.

When my colleague from York South asked you about this supposed $1 billion of reinvestment, you have to know that the way you have gone about reannouncing dollars that were already in the budget, reannouncing the annualization of things that we had all assumed had been calculated into that budget, adding capital into what looked like an operating budget, calls into question how much confidence people can have in your pronouncements about reinvestment in health care.

1720

I sincerely hope that as we go through this process you and your ministry are able to convince us that in fact there is more than empty rhetoric behind your so-called protection of the health care system, because that is an extremely important element if we are going to effect the kind of change in the delivery of health care that we want to do.

As we go through line by line, area by area, I hope you will accede to providing the kind of information that quite frankly you have not been prepared to provide on order paper questions, that you have not been prepared to provide in the Legislature, because that is how we will get confidence that you indeed do have a plan.

I believe it is particularly tragic that the reform of primary health care has been delayed yet again. I would agree absolutely with my colleague from York South that unless we know what the primary care reform is, particularly with the agreement you have signed with the doctors, we cannot have any confidence that we're going to change the system. We see you having signed an agreement with the doctors that means they will continue to wag the dog of health care. They are now in joint committees with you. They have now delayed the primary health care reform yet again. There is no way for you to enforce the agreements that you've made in terms of any kind of a cap, because there's no clawback. Those are very serious problems for you and they are very serious problems when you are dealing with a profession that has insisted on remaining the gatekeeper of the system.

I want you to know that the question about when the nurse practitioner legislation is coming forward is a serious one. I don't know what my colleagues in the Liberal Party have told you, but I can guarantee you that we have great interest in seeing you bring this nurse practitioner legislation forward. We do not see any reason why it needs to go to committee. We do not see any reason why it cannot be passed very quickly. Frankly, given the agreement you've signed with the doctors, the sooner the better because there are lots of people out there knowing that there's no additional money for nurse practitioners in any of this scheme; the minister answered that question in the House. We are very fearful this in fact will come unglued, given the kind of power that physicians have been given in this agreement in restructuring the health system.

I know the minister said we have other committees that meet with other people and they talk about this stuff. Why aren't people at the same table? When you talk about an integrated health care system and you have elements missing like your primary health care delivery, you have elements missing like the chronic care plan, the long-term-care plan, the rehabilitation plan, when you have your committees set up in the usual old silos or with just the powerful players -- and let's talk about those committees.

You have the medical schools, you have the OMA, you have the OHA and the ministry at the table. These are all the big players who have always exercised gatekeeping on this system, who have created the silos in this system, and in fact the integration may be in those systems. There may be better integration within the hospital sector, there may be better integration within the OHIP system, but the other kind of integration, the patient care integration that goes from the moment I need care right through the whole process, isn't there.

Your government's change in terms of responsibility for public health, your government's change in terms of responsibility for ambulance care, your attempted change in terms of long-term care, which I'm delighted that you appear to have withdrawn from, would have made it impossible for that kind of continuum of care to ever be really part of the picture because all of the players would continue to play in their own back yard and the patient would somehow have to figure out a way over the fence or under the stile or through the gate themselves.

I think what we're saying to you as we go through this process is that we believe there needs to be change. We believe that change can be accomplished but we believe it can only be accomplished if there's real clarity and real honesty about what the resources are that we're working with, when there's a real commitment to have all the players have some input into this system, not just the powerful ones who have always had the input, when we actually can see what the end goal looks like.

There are many, many different definitions of an integrated health care system. There are many good articles that we see that tell us about this kind of integration or that kind of integration or another kind of integration. I don't believe that the ONA's -- the nursing association's -- vision of integration is the same as the kinds of talk about integration that the OHA has. I don't hear the same language being spoken and I don't see the same vision for the patient.

I think as we go through this, part of what we can do is clarify how we want to get to that end vision, which I think you've described very well in your speech in terms of wanting to focus on patient care and focus on a continuum of care. I am disappointed that you didn't mention more about the front end of the system because quite frankly our lack of spending on health promotion and illness prevention is our biggest problem. We have very serious issues to deal with around such things as the use of alcohol, the use of tobacco, unsafe driving, the lack of early care when one is showing signs of mental instability, all of which cost us a great deal later on.

We have to have some place in this system where we can see that responsibility being there for all of us. Unfortunately, with the divestment of public health care down to municipalities, that has become totally fragmented and I think will be totally fragmented in terms of the system.

I think there is a role for the ministry in leadership in terms of this change; not a role in terms of trying to manage the change to prevent conflict with some of the parts of the system. I think we have to understand there will be conflict within the system as we do this change, but that if we become confrontational, if the government becomes confrontational, it simply encourages others to walk away from the table and encourages others to use blaming the government as a reason for not moving ahead.

I hope as we go through the figures and we get better clarity about what we're actually looking at -- real clarity about what is happening with the dollars, what the dollars really mean and how those dollars can be worked to lever the kind of change the you're talking about -- we'll all be a lot more comfortable with what we're doing. It doesn't mean that we can resolve issues such as Catholic governance overnight, that we can resolve issues such as job dislocation and job retraining overnight, but what I think we could do is build on the record a commitment by all of us in the Legislature to do exactly that.

The Vice-Chair: The last part of today's meeting will be the response by the minister to presentations. Minister, you have until 6 o'clock for that.

1730

Hon Mr Wilson: I'll begin with Mrs Boyd because it's still fresh in my mind. I appreciate your comments, a very reasoned presentation, if I may say, very balanced. I agree with a lot of it, the willingness to change, as you began your comments. I agree that you happen to live in and represent and be part of an area of the province that has shown great leadership in health care reform -- many times it was ahead of the ministry in terms of its ideas -- a real acceptance, if my reading is the same as yours.

I have a sister-in-law practising on Waterloo Street, a general practitioner, and she tells me that the need for change there is very much accepted by the practitioners and the patients. It's not a top-of-mind topic at all in her patients. They're not worried about their institution or where they're going to go. There's lots of visible health care on the ground already in London, and perhaps that's why. Yes, there are discussions about the mental health services. We had some of that discussion in the House today and we will sort through that.

I want to touch on a few specifics. The union bosses: You take my comments one way, I take them another, but today's reaction in the House -- I'd ask you to read the bill. I am extremely proud, and comfortable with this legislation that Elizabeth and I have worked on. It will give great protections. The gut reaction that they had from the gallery was just wrong -- they hadn't read the bill -- and perhaps was premature. I don't blame them, because I guess they have suspicions of us.

But we have taken great care. There are tremendous protections in a period like no other jurisdiction that's restructuring. You're going to see the stapling of contracts, the full protection of collective bargaining, a very fair and reasonable process. Only if the parties themselves come to a stalemate in their labour relations will they have access to either the temporary commission or the permanent commission.

It is extremely fair. It did not, in your words, give in to the powerful interest of the OHA; it doesn't open up a collective agreement or take away anyone's rights. It goes out of its way, in the most painstaking way in my 14 years, to respect the rights of employees. It just wasn't a fair shake to Elizabeth today at all and is not a fair reading of the bill.

If that's the gut reaction we get, and I see it all the time in health services restructuring, then I have critical words to say about some of the union members. They're certainly off on the wrong mark on this one. Whether they'll ever admit that it's a good piece of legislation, I don't know, but it is a good piece of legislation. It's one that's extremely fair and has abundant protection of rights for employees in it, in what everyone admits will be a very challenging period of restructuring.

I only ask people to open their minds a bit. Read the bill and then criticize its contents as you will, but I think it's very fair and very reasonable.

I very much appreciated both your and Mr Kennedy's comments on integrated health systems. I accept some of the criticism, although the degree of integration today in our health care system is far superior to what I inherited two years ago. I can point today to a very fast-evolving integrated cancer system, where it's one-stop shopping for consumers. I can point today to 43 community care access centres that are almost up and running.

The concept was around for about 22 years; we're finally getting it on the ground. That's true integration, where people go and there's one number and all of the services required for long-term care, including the institutional services, are integrated. I can point today to an integrated cardiac care system, not just one very highly publicized surgery waiting computer system. For the first time in the history of this province, a fully integrated plan came forward from CCN; they're in the process. It will be prevention through to rehab. We've never seen anything like it. Part of the $35 million was earmarked to that research and to make sure we have that plan.

What I like to explain to people is that we're fixing the spokes in the wheel right now. The wheel is a bit wobbly. I think other people are more eloquent than I, because I am absolutely passionate about this business and about this system, and so my illustrations are not always the best. The wheel is a bit wobbly, not everybody is going in the same direction, but I'm fixing those spokes in a rapid way, so that if there is a criticism it's often: "You're moving too fast towards integration." At the end of the day, that wheel will be in perfect unison with itself.

We are moving rapidly. It's not us; I don't mean "we" in terms that I'm responsible for this alone. It's the thousands of people out there who are doing it. Hamilton, through a private partnership with a drug company and our ministry and some more help they'll need from the ministry, is integrating its computer systems. You can go to parts of the province today where the computer systems talk with each other. You can go to Oakville-Trafalgar Hospital, where live X-rays are coming across the airwaves from Sunnybrook. That's true integration.

When people tell me there's no integrated system and there's no process in place, we're processed to death. I said at the Insight conference a week ago that my job is to integrate the integrators. ONA has one vision; RNAO has one vision in process; JPNC, the Joint Provincial Nursing Council, has one; the Health Services Restructuring Commission in its vision document thinks it's going to be the lead on integration.

Everybody wants to be the lead on integration. I agree with you; I say to them, "What does it mean?" I know what it means in the cardiac system. It means if my dad has a heart attack, we pick up the phone, my GP doesn't just fish around for his buddies in med school any more to try and find a place to place my father; they actually phone the regional cardiac centre now, complete integration, one-stop shopping and a buddy system to go with it. Under Cancer Care Ontario, you're buddied up with a social worker or a GP and you are not allowed to fall through the cracks. That is true integration.

I'm extremely proud, and I will go and face my maker and go to my grave knowing that during my period as health minister like no one else I can point and I can tour and I can touch integrated health care systems in this province.

Can we bring that all together in a better way? Yes. There's a lot of work to be done. I see the role of the person who sits in this chair over the next couple of very crucial years as integrating the integrators and making sure there is a set of standards for our computer systems. We're working with the international standards body to make sure we get past this stage of hospitals going out and buying their own computer systems that don't talk to the hospital down the street and certainly don't talk to the community care access centre. We are moving on that.

I make a plea to all those who are spending research dollars and their own operational dollars on developing integrated health care systems that the money now has to be spent on taking all those reports and putting them together.

ONA, the Ontario Nurses' Association, is critical of me in its protests, but I think I had a good discussion with them last week. They're critical that I'm perpetuating the current system and not forcing integration, at the same time your comments and others' are, "You don't want to get into a fight with doctors."

We don't own the system; the people of Ontario do. I don't think it's my job to be the big, heavy hammer all the time. In fact, you said yourself that people are integrating now because they've been given the vision and the dollars and they're doing it the way that's appropriate for their area and their system.

To say, as some have said and others have implied, that we're just throwing good money after bad, that we're somehow doing it in a patchwork way -- there is not a dollar that has gone out in the time I've been Minister of Health that hasn't gone to a Mrs Jones in her living room who needs it.

By the way, there are no gaps, because the way the system works is the day we fund it -- we're on the pre-1985 PSAAB accounting system now -- is the day we make the announcement, unlike the $170 million you announced or the $23-million community investment fund and all those great announcements. I followed them all; it was quite a fascinating period in my five years as health critic, but the dollars didn't flow.

Today the dollars flow and we are on an invoice system, as we've always been, so when I announce that the Red Cross in somebody's area gets money, they can go out the next day and hire the nurses it needs for the expanded program and they also invoice us. We pay those invoices every 30 days, and we will pay those up to the announced amount. There cannot be a gap in services. The only gap we get from day of announcement to the opening of the new or expanded service is the hiring required and the training sometimes required for the new nurses. I reject that there are gaps. I reject, "This isn't real money."

1740

I'm extremely proud of the estimates this year. I can explain every dollar in it. You point, correctly, to a discrepancy, but something we didn't brag about; maybe I should have. We gave hospitals a one-time $400-million investment this year. You pointed out a discrepancy between actuals and spending of about $380 million. It's closer to $400 million. It was an accounting change as we change our accounting system, and rather than take it from hospitals -- and by way, the 11% hospitals have been asked to find, with the growth funding and everything, it nets out to probably less than 8%. It's very doable and we have a number of hospitals today that are in a surplus position, including St Catharines General. I was touring a whole pile of hospitals recently and all of them are at some small surplus, but they can all think of things to do with their surplus, I can tell you that.

There hasn't been a cut to patient care. There's no evidence in this province that there's been a cut to patient care. We do not just welcome the criticism; we want evidence that there is. We have a record budget. We will patch that up if we have to as soon as possible, but we don't have any evidence of this. I've had ONA in, the registered nurses' association in, every group in, and I've said: "I know you have to go and do your thing and represent your union members, but at the same time we all believe in patient care. Please tell me where these gaps are, because I'm not finding them." If we do find them, we are moving extremely quickly, because we have the dollars. In spite of the federal cuts, we've closed a whole pile of ministries and everything has gone into preserving our number one priority: health care.

Integration's important. You mentioned human resources plans -- absolutely crucial. There was a lesson with the NDP in British Columbia. In chatting with that health minister last year, one lesson he told me was -- because it was David Ramsay at the time -- they closed the largest teaching hospital ever closed in North America, Shaughnessy.

Mrs Boyd: Paul Ramsay.

Hon Mr Wilson: Sorry; Paul Ramsay, nice fellow. He said, "Have those human resources plans first." That's why I think the commission has ordered that these plans be in place before anybody goes anywhere. We're about two years away from anybody going anywhere as a result of their directives, and these plans will be in place. Vic Pathe has been appointed in Toronto to be the fact-finder. I think he's highly regarded by both sides. He did London. He was involved in Windsor in a cursory way. He is developing, along with the unions and others, a human resources plan and today's legislation will help that.

The silos: You're right. But no one else has done this either. I've changed the assistant deputy ministers in the ministry. We now have Ron Sapsford, the former chief operating officer of the Ontario Hospital Association, who joined us just a few weeks ago, a couple of months ago. He's now our new super-ADM over a number of previous silos, so there's more than just the minister and the deputy looking across all the silos. But at the lower levels now we start to do the integration that we're asking all of our partners to do, so long before things get to me now, they've had that discussion, across the drug program, from the emergency departments, to the operating plans of the hospitals, right through as many of the silos as possible.

We will continue to restructure the ministry. We're on course for a major restructuring of the ministry. We are beginning phase 2 of that. Phase 1 was to completely change the way we do business at the senior levels, and soon we will change business the way it's done in our regional levels.

Our reinvestments are all in the book. They're real dollars. They are flowing. They're not on an ad hoc basis. As I said to the nurses' union: "What do you want me to do? Starve services to people because suddenly overnight you think we're going to move to this new province-wide integrated system?" No. Every dollar that we're announcing is going to some service demand.

By the way, there is no hospital that got a dialysis unit that didn't apply for it. It was a competitive bid. If a CEO is telling you he got something he didn't want, then he shouldn't have applied for it. It was an RFP process, the first of its kind in 10 years: highest quality, best price. In fact, congratulations to the hospital, Mr Kennedy, because they had to sharpen their pencils pretty hard to compete with private sector operators, with nurses who now own and bid on dialysis units. There can't be a hospital that got something it didn't want. They had to bid for it and they probably bumped out a few other people to win the contract in the first place.

On the $960 million, I'll admit about $200 million of that is capital. That is for the community health centres in Parkdale -- we're redeveloping three of them -- and for long-term care at York Central Hospital. We used to call it Richmond Hill Hospital. I don't live too far away from that in my riding.

By the way, that's the first new licence in about 10 years where we've licensed new nursing home beds in the province. It's nice that we have a $100-billion debt and inherited about a $12-billion deficit, but neither of your two parties put in any new nursing home beds. You rejigged and redid it and licences from the north were moved to the south, but no new net ones were added in the last 10 years. We are proud to be doing that and that's been part of the reinvestment.

We're just finishing a bed study to see what the needs are now. We know, for example, that we are underbedded in the Georgetown-Halton area. There's going to have to be future reinvestment out that way, immediately, and in Metro Toronto. I think the commission is making the point in its interim report. Certainly in the two-foot-thick pile of background material there's lots of evidence that we're going to need some more long-term-care beds in Metro. We're working on that right now.

Primary health care: I agree with you 100% that it seems very slow. I'm the fellow who put his reputation on the line, I suppose, last year when I thought that by Christmas we could have a couple of pilot projects. I had no idea -- I say this to everyone who asks me and in all of my speeches -- that it was so complicated. Many of our multidisciplinary partners saw it as a way to get into OHIP and that opened up a can of worms I didn't anticipate. I never announced that suddenly various therapists were going to become fully part of OHIP. We're not looking for an expansion of OHIP services. We have the largest roster of benefits of any province by far, bar none, in this country and out. We pay for far more things on our OHIP and our drug plans than anybody else does in the country. So we aren't looking for an expansion there.

Second, contrary to Star editorials and others, we're not in the business of giving freebies to doctors. They did not get a fee increase. Every time we go to have those very local discussions with the doctors' groups about a group practice model, they want significant incentives to go off fee for service. They want sweeteners. Frankly, that has been the major obstacle to negotiations. I'm not giving them sweeteners to get part of an integrated, capitated primary health care system. They are difficult negotiations. I don't regret one moment of my negotiations with the doctors.

Do you know what Quebec's answer was to CMPA, the Canadian Medical Protective Association, the malpractice insurance? They want to go alone. That's what they think. At least my call for Justice Dubin to come in and do an actuarial study of it shone light on an issue that I thought -- when I was assistant at Health and Welfare Canada, I couldn't believe the provinces open-endedly paying these invoices and the huge demands. It's how the Liberals got the doctors off the front lawn in 1986: You set up malpractice. You say you'll pay any increase above 1986 levels. Well, lo and behold, we've seen quadrupling.

Once the public purse got involved, the doctors' premiums -- the doctors themselves should complain about this, but they don't, an unlegislated -- it's not an insurance body, it's a board owned by doctors, in Ottawa, run by Dr Stuart Lee. There is no legislation in place other than an incorporation under a federal act many years ago, but it's not an insurance company.

It was unaudited until I came along. I'm the first minister to ever ask for an audit. When I came in in January 1996, this government was confronted at that time with about a $40-million increase in CMPA, and there's no way we're paying $40 million to anybody anywhere in this province until we ask a few questions. Why did they need a $1-billion fund when the reserves are significantly more than any of the reserves I can find in the United States? What are they going to do with the $1 billion? The lawsuits are not here.

1750

Our courts capped -- by the way, you were an excellent former Attorney General. I didn't mean it that way. You were an excellent Attorney General while you were at it. I thought your grasp of the issues was most impressive for a non-legal background. You would understand better than anyone in this room that the courts are not awarding multibillion-dollar or multimillion-dollar awards for life and limb in this province. They have been very reasonable. The whole premise on which CMPA was established, which by the way had no actuarial study that was available -- Margaret Mottershead tried on many occasions before we made any decision on CMPA to get Dr Stuart Lee on the phone and say, "What are your actuarial studies and why are we paying a $40-million bill?"

Why doctors aren't screaming bloody murder is beyond me. Why? Because they have this exclusive deal with the province of Ontario made in 1986 that we will pay any increase regardless of what it is. So I have no regrets. Did it take me two years and 11 weeks of my life to get this deal? Yes. But I didn't give them a fee increase. I recognized after extremely hard bargaining that 1.5% each year after a number of years of nothing for growth and aging is very reasonable.

By the way, we fund everybody else that way. Hospitals are funded for growth and aging as part of the formula. Everybody else in the system is funded that way. Doctors were an anomaly. We didn't fund them that way. They have no automatic formula they come up with. Community health centres are funded for growth and aging. Name a centre, name an institution, name something, and our formulas recognize growth and aging. Doctors didn't get that, and no discussion was allowed since 1993, according to them, on that topic.

I have no regrets. I've taken terrible personal hits for it. But I like to think I was as tough as humanly possible during that period of time and in the end still able to get a deal that will bring some stability over the next three years.

This isn't a freebie. There is a lot of work to be done in those committees. There are goals and objectives to be met. If they're not met, it will be a breach of the agreement and we may be back at square one. There's a lot of work to be done on both sides. I met this morning with the new president of the OMA, Dr John Gray, and he agrees that there's a tremendous obligation on both sides now to move towards integrated health care systems and to move towards more alternative payment plans and real reform of the health care system. He believes very much that now we have some stability for three years, a three-year opportunity, we will make great progress over the next three years, because the doctors will get off some of the monetary issues and start to look at some of the system issues we need them to look at.

Promotion and prevention: I think you make an excellent point there. There does appear to be some slippage there in the estimates. We can explain that fully. But we have, and it's credited to your government, the best tobacco strategy in Canada by far. Every time I get interviewed on it, it's as if we should do something more. Actually, the obligation is on everybody else in Canada to catch up, frankly.

Public health today: In public health, we don't have levers. This is the true mythology. We believe that under Who Does What we will be able to put in place legislation that has real teeth. If today a municipality doesn't deliver a mandatory program, what do you do? We're not funding most of them 100%. The range is 25% to 75%. We don't fund the big municipalities 75%; we fund more towards the 30% range. Our levers are very little.

For instance, recently there was a municipality that does not want to do tobacco education. It's a very real municipality. It was brought to my attention last week by the chief medical officer of health. He said, "Jim, what do I do?" I said: "I don't know. Try to embarrass them through the media." So that's what he's going to do this week, he's going to try to embarrass them through the media. I think we're going to have far better teeth.

Where the employees are now, most of the employees in public health are employees of the municipalities now anyway. They own the offices, they own the infrastructure. We will continue to set the standards, and those mandatory programs will be delivered or there will be penalties. The penalties are still being discussed with AMO. Jack Carroll is leading that discussion. There will be penalties for not delivering programs and they won't just be financial levers; there are many other ways to do it.

We have done a lot in promotion and prevention. The pneumococcal and hepatitis B, the first of its kind; credit to Dr Richard Schabas. When I came, he said, "The best thing you can do for promotion of public health in this province is province-wide vaccination programs." There you lock in a guarantee against disease for generations, once you immunize your population. It's a tremendous payback in cost-effectiveness in the system. Can we do more? We will do more, but those programs are the first of their kind and I'm extremely proud of them. Again, the rest of the country has to catch up. Nobody is inoculating their seniors as we are. No one has done the school kids as we have. Having been chair, just over the last year, of Canada's health ministers, I know we are the envy. We had the money and the political will to go ahead and do those things.

Very quickly, I would like to table with the committee, which I will bring with me next time -- tomorrow I have to go to Tom Coffin's funeral and the parliamentary assistant, Dan Newman, will be with you, but I will try to make sure we bring along the funding formula for JPPC.

When people tell me that growth isn't recognized, they're wrong. They tell me they're in a unique area. In every area of the province I go to, everybody's uniquely underfunded. Nobody funds health care per capita. It would be crazy. You know that; anyone who's been in the system knows that. We often use per-capita comparisons among provinces for politicians' sakes, but it doesn't make any sense. Out in Mr Conway's area, where you have a very large concentration of seniors in some parts of that riding, and in Leo Jordan's riding, we spend six times more per capita in health care because they're at a stage in their lives when they need six times more care.

An area like Barrie, which is very young and has huge growth -- you could spend all your $25 million in Barrie if you were stupid and had a formula that just recognized per capita growth, but in Barrie they're young families. Their biggest need is obstetrics. That's where we've had a lot of obstetrical problems -- not Windsor, but Barrie. They're not using the cardiac system yet; they're not at that stage in life. Their eyes haven't gone yet. Their bodies haven't got to that anatomical stage where they need more health care.

We fund based on a needs-based formula that's continually being refined. I'm very proud of our formula. The formula established two years ago by the JPPC is a first of its kind. It's the envy of the country and it's recognizing all these little things in the population that need to be recognized in order to properly fund health care.

My last thing: Mr Kennedy mentioned some discrepancy in the drug plan we weren't spending. Please advertise to your constituents that the money is there for Trillium drug. You'll see that line item says we've underspent by several millions of dollars. It's because we don't have the applications. We had a lot of problems with the slowness of the application process. We've speeded that up. We're pretty well as up-to-date as you can be. That's all the spending we will. This is estimates. You may see a whole pile of people catch on to it this year.

I met with the AIDS groups the other day. Dr Anne Phillips, by the way, ladies and gentlemen, is one of our world leaders on AIDS. She said she has just finished a survey of all North America and Canada and we have the most generous program for anybody, but she was particularly talking about HIV and AIDS. That's a credit to the previous government for bringing in Trillium, it's a credit to us for lowering the deductible to $350 and it's a credit to us for adding 460 new drugs, including some hugely expensive drugs, to the formulary.

The final thing I'll say is about the article that Kelly Toughill did in the Star -- you picked up on it and it's just wrong -- about most of the efficiencies in restructuring not coming from closing buildings. That is true; closing buildings saves you X millions of dollars. But we are told by every expert, and the commission's getting the same advice, that the only way to get the clinical efficiencies -- because as Minister of Health you cannot order a doctor how to conduct his or her daily business. They decide exclusively when to admit a patient, when to discharge a patient. They decide exclusively what is medically necessary in this province; the Minister of Health does not.

Therefore, the clinical efficiencies come -- my uncle is a cardiologist, and everyone tells us this -- when you get doctors together on the same site -- obviously we're talking about multisite towns -- and the peer pressure is: "Doctor, why do you take an hour and a half? You're holding us up, when I take 40 minutes for the same operation. Could I show you, Gerard, how to maybe do that surgery a little faster?"

That's the clinical efficiency. It's not rocket science; it's human nature. It's hard to show you a chart about it. What you're seeing from the Health Services Restructuring Commission is its guesstimate -- they are experts and they're receiving advice from experts -- on what clinical efficiencies can be achieved, given best practices elsewhere in the system. Nobody, by the way -- and this is a rule they must follow, we're trying to encourage them to follow in our public responses to them, particularly in Metro Toronto. We don't want them setting stratospheric benchmarks that nobody else has achieved. We only want them to ask other players in the system to achieve what others are doing. Thirty per cent of our hospitals are at those benchmarks in one category or another, so nobody is being asked to do the impossible. Doctors, in terms of the clinical efficiencies -- it's very conservative.

The final thing I'll say is about targets. Ms Boyd, you were exactly right in terms of saying it was a difficult situation when I came into office. The president of the Ontario Hospital Association at that time, David Martin, said, "If you don't set some financial targets we'll never get started," and you acknowledged that both ways in your remarks. So after a lot of study we set the $1.3 billion over three years. It turns out we were just about bang on. The commission to date has identified $1.1 billion, and it hasn't even finished, in clinical efficiencies, in buildings, in maintenance, in huge administration.

It's not like we don't have a plan. The sunshine law was done when we came to office so people would start to see the costs of administration in our health care system. It's immoral. It's awful. Nurses have complained about it for years but the facts weren't on the front page of the paper. As a government we passed the sunshine law and the facts are on the front page of the paper now.

We have a lot of administration. It's a fine line. We need those same administrators' help to get some of the reforms done, so it's always tricky. But we set numerical targets and we said -- the Premier said it, I said it the day it was announced, and the finance minister said it -- we wouldn't ask anyone to do the impossible. Here's your 18%. We've now come to the point where the third year is going to be very difficult so we've set that aside, because we're true to our word. We're not going to ask people to do the impossible and they are not allowed to cut patient services. It's all about increasing services and getting rid of what we don't need and about what we do need.

If this doesn't sound like a plan to you, I don't know what ever will. But there is a plan, there is a vision. For the first time it's written down in the business plan. For the first time you have vision statements from the Ministry of Health. You've got pamphlets, you've got everything, you've got commissions, and we're all pulling on the oars in the same direction.

The Vice-Chair: Just before we adjourn, the minister has informed us that he will not be available tomorrow as he is attending the funeral of Constable Coffin, who was a friend. I guess the committee has the option of either dealing with the parliamentary assistant or not meeting. Is there any discussion?

Mr Kennedy: I would suggest, especially given the very interesting issues raised by the minister, that we defer discussion. Certainly respecting very much the very genuine reason why the minister can't attend, I would suggest we defer it until the minister is next available, presuming that would be the following week.

Hon Mr Wilson: If you want to do that, that's fine. It's up to the committee. But you might want to do some of the technical stuff tomorrow with the deputy. I mean the numbers stuff and stuff that I would just bore you with anyway. Margaret is turning all red here. She doesn't want to go through that. But you may want to do some of the technical questions. There is an explanation for everything and the accountants go through all this.

Mr Kennedy: In the list of issues we have and the limited time we have, I certainly respect that suggestion, but I just think issues have been raised in both of our statements that are fresh, that are the kinds of things I think people want to hear from this committee. If the minister is willing, I think we'd like to defer.

The Vice-Chair: Any further discussion? Do we have a motion for deferral? Agreed.

Mr Trevor Pettit (Hamilton Mountain): So we don't meet tomorrow.

The Vice-Chair: We don't meet tomorrow.

The committee adjourned at 1805.