Assemblée législative de l'Ontario

MINISTRY OF HEALTH

CONTENTS

Wednesday 24 June 1992

Ministry of Health

Hon Frances Lankin, minister

Michael B. Gain, acting manager, financial management services

STANDING COMMITTEE ON ESTIMATES

*Chair / Président: Jackson, Cameron (Burlington South/-Sud PC)

*Vice-Chair / Vice-Présidente: Marland, Margaret (Mississauga South/-Sud PC)

*Bisson, Giles (Cochrane South/-Sud ND)

Carr, Gary (Oakville South/-Sud PC)

*Eddy, Ron (Brant-Haldimand L)

*Ferguson, Will, (Kitchener ND)

*Frankford, Robert (Scarborough East/-Est ND)

Lessard, Wayne (Windsor-Walkerville ND)

*O'Connor, Larry (Durham-York ND)

*Perruzza, Anthony (Downsview ND)

Ramsay, David (Timiskaming L)

Sorbara, Gregory S. (York Centre L)

Substitutions / Membres remplaçants:

*Sullivan, Barbara (Halton Centre L) for Mr Ramsay

*Wessenger, Paul (Simcoe Centre ND) for Mr Lessard

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

*In attendance / présents

Also taking part / Autres participants et participantes: Lessard, Wayne (Windsor-Walkerville ND)

Clerk: Greffier: Carrozza, Franco

The committee met at 1618 in committee room 2.

The Chair (Mr Cameron Jackson): I'd like to call to order the standing committee on estimates. Before the committee are two housekeeping matters I'd like to resolve before we commence the hearings on the Ministry of Health: the subcommittee report and our budget. The clerk has tabled those. Any discussion? If not, the Chair would entertain a motion for approval.

Mr Gilles Bisson (Cochrane South): Sure. I didn't want to be the first one. I move we accept the budget of the estimates committee, along with the the subcommittee report.

The Chair: Thank you. Any discussion on the report and the budget?

All those in favour, please indicate. Opposed? The motion is carried. Thank you.

That will be communicated to the House leaders, maybe even this afternoon.

Mr Robert Frankford (Scarborough East): On a point of privilege, Mr Chair: I'd like to take the opportunity of correcting my own record.

The Chair: Feel free to do so.

Mr Frankford: You may recall on the first meeting, when the minister was here before, I got into the topic of the US health care system and I believe that I referred to the possibility of getting revenue because of their excessive administrative costs and I threw in the figure of something like $20 billion. I have a paper here that has more accurate figures. The figures here are subject to controversy, but one figure is $46 billion and other figures from very reliable authorities say from $69 billion to $87 billion. So I was clearly in error, and this might be useful to the committee.

The Chair: Thank you for correcting the record. Seeing no other business, this committee stands adjourned until the minister arrives.

The committee recessed at 1622.

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MINISTRY OF HEALTH

The Chair: The committee is now reconvening hearings on the Ministry of Health estimates. I'd like to welcome back the minister. Following in rotation, two hours and 28 minutes remain. I'd like to recognize Mrs Sullivan. Prior to doing that, does the ministry staff have any of the questions requested by the committee to date ready to table with the committee members?

Hon Frances Lankin (Minister of Health): Mr Chair, if I can respond on that point, no, the answers aren't ready. I apologize to the committee. As many committee members will know, I was in Hull for three days last week at a federal-provincial ministers' meeting of health and finance ministers and at a national physicians' conference in Ottawa for the first two days of this week. The ministry staff have prepared written responses to the questions that were asked, but I have been unable to go through them all. I will undertake to do that in the next couple of days and get most of the responses to the questions that were tabled prior to yesterday. There will be a couple that will still be outstanding, for example Mrs Sullivan's extensive question on the use of consultants throughout the ministry. It was taking a considerable amount of person-time to compile a response to that, as one can only imagine.

There are a couple of others like that. I should indicate that the questions that were tabled yesterday, as I review them, are extensive, detailed questions far beyond what is normal in an estimates situation. These will take us some considerable time to respond to. But I do undertake to the committee to try to get them for you as soon as is possible.

The Chair: Thank you, Minister. Mrs Sullivan, you have approximately 45 minutes.

Mrs Barbara Sullivan (Halton Centre): I want to note for the record that, according to the original time that was scheduled for review of the estimates, the opposition parties would each have had something slightly over 80 minutes. We are now down to 45 minutes and we're very concerned about that. This was not the intention of the committee when it established the hours and minutes available for the defence of the estimates and for the opposition parties to obtain information from the minister. I want the record to show that.

When we last left questioning, which I believe was on June 9, the minister was responding to a question from Mr Wilson in relation to in-home services. In hearing the minister's response at the time and reviewing the response after, we saw the minister take us down a path where the response to the questions relating to commercial versus non-profit sector in-home care to my mind was somewhat confusing in that the minister took us into the integrated homemaker program as being the major area where there were problems in the provision of services on a competitive basis: non-profit versus commercial.

Unless there has been a change we don't know about, the integrated homemaker service is not funded by the Ministry of Health. I wonder if you could elaborate on where you were going in that discussion at the end of it.

Hon Ms Lankin: I will attempt to do that. I'm sorry if the remarks I made were confusing. I think I attempted to indicate at least that the integrated homemaking program was an example of in-home services where the growth in the activity of the commercial sector was quite notable since the introduction of that program in 1986 or 1987. It relates very much, I think, to the whole in-home services program, which is of course part of the long-term care redirection within the joint division between the Ministry of Community and Social Services and the Ministry of Health.

The issues I raised for the committee to consider were issues that have been raised for us as we have been out in consultation on the long-term care redirection. As the member knows, we have had a very extensive consultation.

One of the things we heard very clearly from the provider sector but also from the consumer sector was concern about the growth of concentrated commercial activity in some large urban areas and the shift of market share from non-profit to commercial firms where the non-profit firms were still left with the responsibility of delivery of service outside the urban areas in larger, more difficult geographical parts of the province, and the costs of servicing those areas therefore were becoming very difficult for those non-profit firms to continue when they were losing their market share in the urban centres where the cost per unit of service delivery is somewhat lower. Those are concerns we were hearing during the long-term care redirection, and I was attempting to indicate for the committee, in response to Mr Wilson's questions, that it was an area I think for us to consider as we're looking at developing policy response to the consultation on long-term care.

Mrs Sullivan: In addition to the impression of urban concentration of non-profit services, has the ministry done any analysis to review where and what services the commercial sector is providing and at what level of cost to the contractor, if it's a municipality or whoever the contractor is?

Hon Ms Lankin: We're in the process of doing that very analysis in response to the concerns that were raised during the consultation, so that will be able to form part of the materials I and my colleague ministers review as we are developing a position to take to cabinet for policy with respect to long-term care.

Mrs Sullivan: I'm going to once again underline the question that was presented by Mr Wilson. Is it your intention to move further into the non-profit sector for reliance for service delivery while maintaining public administration, or are you satisfied with the mix of commercial and non-profit delivery?

Hon Ms Lankin: I'm unable to answer the question at this point in time because I have asked for that kind of information analysis to be provided to myself and to the other two ministers responsible for the long-term care redirection so we may look at the accurate data in light of the concerns that were raised during the consultation. No decision has been taken, and in fact at this point in time there is no recommendation that has yet been formulated to take to my cabinet colleagues.

Mrs Sullivan: When that material is available I wonder if the minister could share it with the members of the opposition -- the actual data you will be using as a base for decision-making. I think those are useful data. There is, as you know, because of questions that have been raised in the House and elsewhere, some level of discomfort and speculation about what decisions will be taken in the absence of those data. If that could be made available, we would certainly appreciate it.

Hon Ms Lankin: I fully expect that as we develop our cabinet recommendations it will form part of the cabinet submission and that once cabinet has taken a decision and there are policy decisions that have been taken and we will be announcing, it can form part of the backup material and we can ensure that opposition critics get copies of it.

Mrs Sullivan: I want to move now to an area which formed part of the discussion at the federal-provincial meeting, and that relates to the remuneration for physicians' services.

I understand from a report in the Globe and Mail today that you had indicated an inclination to move from the fee-for-service remuneration model into other models, yet on other occasions we have also noted quotations from you indicating some discouragement and indeed criticism of some of the other models that are being put into place, including health service organization capitation models. Can you put on the table for the committee where you see the development in these areas now, and if indeed you are in discussions with the OMA, a joint committee, in relationship to elimination for fee-for-service remuneration?

Hon Ms Lankin: We're certainly not in discussions with the Ontario Medical Association about the elimination of fee-for-service. What discussions have taken place at a national level among the ministers of health, at the academic level in reports like the Barer-Stoddart report and in fact at the physicians' human resource management conference that was held the last two days in Ottawa, indicated everyone is now coming to an agreement that there are problematic cost drivers and inappropriate incentives in the current fee-for-service schedule and that perhaps we should be moving towards a phasing out of that. Some of the workshop recommendations at the conference talked about perhaps moving to phasing out or substantially reducing reliance on fee-for-service over a five- to six-year period. There have been no decisions taken with respect to that as a definite action plan, but the issue of concern has been flagged.

With respect to the discussions that have been taking place with the Ontario Medical Association and the joint management committee, if I can separate out first of all discussions with the JMC from negotiations that are actually going on around the contract in the fee-for-service schedule, at the JMC there have been discussions around the continued increase and the rate of escalation of costs of physicians' services over the last number of years and joint approaches to better management of those increases in costs, including looking at, for example, the fee schedule to see where there may be appropriate or inappropriate incentives within the fee schedule, as well as looking at other forms of payment models and the possibility of moving more towards those. Those have been sort of broad-stroke discussions, however. In the actual negotiations, there are currently on the table proposals with respect to the structure of the fee schedule, and those are subject to negotiation.

The comments you made about any concerns I might have expressed with respect to the health service organization model of alternative payment are ones that I think need to be put in the perspective that we were under negotiations with the OMA at that point in time. We have since concluded negotiations. There is a new health service organization, HSO, model contract, and ratification has been proceeding on that. In fact I think the majority of HSOs have signed up on the new-contract basis.

I can tell you in brief form some of the changes we made from the past program to the new program. Concerns raised by government and by some members of the HSO sector themselves, those in particular that are run by community boards or have community advisory boards attached to them and group practices, were that the growth in the HSO model tended to be in the solo-physician practice and tended to be in parts of the province serving parts of the population that had a fairly healthy status, and therefore programs like the ambulatory care incentive program that was contained within the HSO model were in fact benefiting that solo practice without those moneys being reinvested in health promotion, outreach programs or using alternative health care providers in delivering specialty programs, which I think was what was envisioned originally by the ambulatory care incentive program.

We have eliminated ACIP, the ambulatory care incentive payment, and have replaced that with program funding for health promotion and illness prevention kinds of initiatives, which I think is true to the spirit of what was intended by the previous government when the HSO model was put in place. It's just that with any new model you find out after a period of time what works and what doesn't work and what refinements need to be made.

We also have done some adjustment around the negation factor, which is the factor to negate the capitation amount per patient, dependent on the individual patient's use of other parts of the health care system. Again that is in line with making this a program where the incentives and disincentives will truly work to try to help the provider have the time to provide good-quality care and do a lot of health promotion and illness prevention work. I think it has really improved that alternative payment model in terms of those refinements that were made during the negotiations, and I'm quite pleased to say I remain, and the government remains, very supportive of the HSO model as one form of alternative payment model.

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Mrs Sullivan: When you talk about changing the negation formula dependent on use, are you talking about geographical use or specific other facility use or other professionals? What specific areas would be affected by a change in the negation?

Hon Ms Lankin: Mrs Sullivan, I believe it's the actual amount of negation that was changed as opposed to its application, but I can provide you with a copy of the model contract and you would be able to see that for yourself.

Mrs Sullivan: I think that would be a useful area to investigate. Certainly some of the problems with the HSOs were in being negated for emergency treatment or for treatment by a physician in another community at a substantial distance from the community in which his or her own HSO was located. The negation naturally affected the kind of approach they were able to take in terms of health promotion and prevention programs.

Hon Ms Lankin: When I said that, I'm not sure whether I said we lowered the negation. I'm not sure what words I used. We increased the amount of negation is what I had intended to say, and just thinking back I'm not sure if I used the right words.

Mr Michael Gain: It was "changed."

Hon Ms Lankin: I used the neutral. We changed the negation.

Mrs Sullivan: So has it been increased or decreased?

Hon Ms Lankin: It's been increased so that there is more of an incentive to keep your patients from using other parts of the health care system inappropriately.

Mrs Sullivan: Therefore, by example, using the precise example that I've used, if a person has to seek care in another part of Ontario, the local HSO will in fact be negated and will suffer as a result of that.

Hon Ms Lankin: I'd have to get you a specific response on that. I actually don't know whether there are any exemptions for a person on holiday, for example. That might be a good case model of what you're suggesting.

Mrs Sullivan: Business travel?

Hon Ms Lankin: Yes. I don't know what the existing program had. I don't believe we've changed anything with respect to that. We've only changed the amount of negation in terms of the program but we will provide you with the model contract. I believe the ratification was completed; if not, it will be within a period of the next week or so and we'll be able to send you copies of the contract at that time.

Mrs Sullivan: We'd be interested in seeing that. I want to go back to the physician fee-for-service question for a moment. One of the quotes, I believe in the Globe and Mail, that you used was that the 30% of medical services that studies have shown to be inappropriate may in fact be increased through the fee-for-service payment. What evidence do you have to show that specific link within this jurisdiction?

Hon Ms Lankin: Do you have the quote that you --

Mrs Sullivan: I think it was in the Globe today. I just don't happen to have it with me.

Hon Ms Lankin: I'm not sure I made that exact link between those two issues. Actually, we probably would have a copy here. Once I've got the actual wording I can perhaps explain it better.

I know that in the speech I delivered, and copies of that are available so we could check the exact wording, I talked about the fee-for-service system. Those who have studied it and the critics of it have clearly indicated that they feel there are inappropriate incentives in the system and inappropriate disincentives. For example, the fee-for-service system works strongly against doctors who want to practise what critics would call high-quality medicine that may involve taking a significant amount of time with certain patients, being able to do health education, health promotion work with them, as well as being able to go beyond a quick history in terms of trying to get background information that might also lead to additional answers to the person's health problems.

With respect to the rule of thumb that researchers talk about of 30% of medical services being inappropriate, that ranges from a whole lot of things -- for example, surgical interventions. One of the examples I used to support that is a study that has been done by Dr Wenburg in the United States with respect to prostate cancer in which he has developed an interactive video that patients can use that provides them with background information around surgical intervention with prostate cancer and alternatives to surgical intervention.

They found that when a patient used that, up to about 50% of them choose not to have surgical intervention and that there may be a very strong relationship between the issue of truly informed consent and patients' values and inappropriate use of surgical intervention. This is one of the areas of investigation and study that is going on that I referenced.

Mrs Sullivan: We've heard Bouchard talk about 50% and we've heard you talk about 30%. What in fact we're seeing when we're looking at the studies, most of them not done in our own jurisdiction, are studies about specific procedures that relate specifically to those procedures, such as the one you have just indicated. There are others relating to the kidney and so on. But what I don't understand is what strength you have in extrapolating from data from specific procedural interventions, whether there is surgical or other treatment, and extending that right across the board to assume that 30% of medical interventions are indeed inappropriate.

Hon Ms Lankin: I think that's a fair comment of concern and I would suggest that I haven't made that kind of broad extrapolation. In most cases where I have made reference to the researchers' data I have cited that they are in fact certain researchers' data and that they indicate that perhaps up to 30% is of not proven value. Time and time again that is what seems to come out of research.

I've also indicated that I don't know this to be the case, but as the Minister of Health, along with my colleagues in every other province, we have talked about this. It is, I think, not prudent for us to ignore this mounting research that is critical of the current state of medical practice and that it does call out for some response. Now I think the response should not be a pre-emptive strike with respect to cutting services in certain areas. I think it should be what most provinces are moving towards, which is a measured and scientific evaluation of the health outcomes of certain medical procedures.

For example, the Institute for Clinical Evaluative Sciences here in Ontario at Sunnybrook Medical Centre, headed up Dr David Naylor, I think will provide us with very important work that the medical profession and other health professionals in government can look to, to help us make good decisions about expenditure of health resources in the future.

Mrs Sullivan: I suppose that's what I want to underline. Until the work of Dr Naylor and his group is more advanced, building an expectation of a 30% cut in medical interventions as a base to a changed delivery of service may be an inappropriate approach to be taking now. The exploration and the real analysis and study in our own jurisdiction isn't complete.

Hon Ms Lankin: I think there's a very important reason to keep underlining the nature of the research that is being done and the nature of the findings that are being arrived at, and that is that I think the consumer and the medical profession and other health care professionals need to be thinking about this issue of the appropriateness or inappropriateness of various medical treatments.

For example, where we do have good research data and clinical guidelines have been developed -- I'll cite the example of both cholesterol and, more recently, the work of the college of obstetricians and gynaecologists, which has done clinical guidelines around Caesarean sections -- we find that there isn't an atmosphere of receptivity among the medical profession for changing its practice based solely on receiving guidelines from some scientific review. There has to be much more of an interactive discussion taking place in the medical profession and in the community with their patients about these findings and about the impact they should be having on medical practice.

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We know, for example, from some of the work that's been done over the years by CHEPA, the Centre for Health Economics and Policy Analysis, and also more recently by the college of obstetricians and gynaecologists and its development of clinical guidelines for Caesarean sections, that the promulgation of such guidelines in and of themselves does not change medical practice and that it's very important for there to be opinion leaders within the profession who interact with their colleagues. I think this is part of what we try to help foster through our focus on this broad issue, through the sponsorship of an institute like the Institute for Clinical Evaluative Sciences and through the sponsorship of conferences like the national physicians' conference that was just held over the past two days. It gives us an opportunity to really focus in on this issue.

I guess the other point I should stress is that in these studies it is not suggested that the 30% rule only is indicative of inappropriate services; it also suggests they may be of unproven value. I think that's the area we try to move to with the more rigorous application of measurement of health outcomes with respect to various medical treatments.

Mrs Sullivan: If I can move back to physician remuneration, are you looking at a payment model as perhaps a pilot of reimbursement of physicians on a salary basis outside of community health centres?

Hon Ms Lankin: Of course there are the CHCs; the health service organization, as you know, is a capitation base which is not exactly a salary base. There is some developmental work taking place with respect to comprehensive health organizations. The details of that are not yet well developed as to on what basis physicians would be paid within that structure. We are currently in negotiations with academic health science centres around alternative payments for physicians who are educators currently having to fund that education by clinical services on the fee-for-service basis. I think everyone feels that's an inappropriate way to fund an education research setting

Outside of that, there aren't any proposals that are active within my office at this point in time. There is a discussion that I've asked for with respect to the development of a more comprehensive approach to our delivery of primary care services, which is broader than physicians' services, but that's only in its infancy. I don't believe it would even have begun to address any issues like a pilot project for alternative ways of paying physicians and salaries.

Mrs Sullivan: If I could move to provincial drug programs now, as discussion relating to reform of the drug benefits plan proceeds, will you be using the Lowy report as the strategic base for those discussions and policy decisions?

Hon Ms Lankin: Yes, we have been to this date. There will be some areas where, as we consult, there may be different approaches arrived at, but certainly it is an important document to form the basis of the work the drug reform secretariat will be undertaking.

Mrs Sullivan: Are you considering at all expanding the drug program to make it universal for everyone in Ontario and with perhaps a means test or a tax credit clawback laterally?

Hon Ms Lankin: The terms of reference of the drug reform secretariat include looking at the issue of eligibility and the breadth of eligibility for access to systems under the drug benefit program. Of course that squarely places on the table that if you were looking at something like extending the eligibility, how would you fund it? Would you look at the measures you've suggested or a co-payment measure? You may know there was some speculation that we were considering the co-payment feature in the early part of the initiatives we undertook under the drug reform secretariat. We've rejected the possibility as a unilateral measure.

I think the question of whether or not the drug program should be reformed for broader coverage in the population and/or how that is funded is one that we will hear some response from in consultation, but there are no plans at this point in time to implement that kind of a change. Let me put it this way: I'm willing to ask the question and to have people talk about that. It was one of the Lowy recommendations of a restructured program. I'd be interested in how consumers, seniors, the pharmaceutical industry, the pharmacists and doctors feel about that as we go through this period of consultation, but there are no plans or recommendations in government to proceed directly with that at this point in time.

Mrs Sullivan: You can understand that we're working against the clock on time here. I want to leap, in terms of expansion of existing programs, into the recommendations as a follow-up to the SARC report, the Time For Action report, which has just been made available.

One of the recommendations from that report was that the special needs programs, which are now being delivered on a totally inconsistent basis through the province depending on the municipality and the extent of the programs that are offered by the province, where those special needs requirements are to be available, they should be available universally and delivered through the health care system. Are you looking at that?

Hon Ms Lankin: We haven't. The recommendation came forward and it will have to be taken up, but at this point time I have not done any work in my office on that issue yet.

Mrs Sullivan: Is that something you would see as a priority for being on the table?

Hon Ms Lankin: I think the Minister of Community and Social Services will certainly be urging all her colleagues to move to look at the issues that have been dealt with in this report, so I think it is an important issue. At this point in time I am unable to comment specifically on the recommendations or on any kind of possible response to that.

One of the things I think is related, although not directly on points, is the issue of children's health and some of the special needs programs that were addressed there. Certainly children in need fall into the category of those who would be helped by those programs. We have highlighted that as a priority for us to move on. Comsoc is the lead ministry. Comsoc, Education and Health, along with some other ministries, but those three ministries in particular, are looking at trying to much better integrate their programs and ensure much better delivery of service to children on various health issues.

Mrs Sullivan: I think one of the things that both SARC and Time For Action, the Moscovitch report, do is to indicate that the universality of health care programs be expanded to ensure that if a nutritional product or an assistive device is required that would otherwise not be available if the person wasn't on social assistance, the need for that may indeed push them over into social assistance. This is a way to move them out of the cycle of poverty and the social assistance cycle. It seems to me that is a rational way to move in the health care system and should be a matter of priority.

Certainly in my constituency office today, the number one issue is people asking, first, how to apply for welfare, because they're being released from levels of work where they have never even considered how to apply, and second, if they're able to hang on, to stay off either welfare or family benefits, what will put them over the edge is the need for assistive devices or other health care products or services that are only available through the special needs program. They don't qualify for the drug benefit card and they don't qualify for other assistive devices because they're not on social assistance.

Hon Ms Lankin: There are a number of assistive devices that are applied on a universal basis to certain age groups, and there are some top-up provisions that are contained within municipal special needs adjustment programs.

Mrs Sullivan: If the municipality provides them. They are not universally provided across Ontario.

Hon Ms Lankin: I realize that. I was just wondering if you were talking to the top-up provisions specifically as being an area that should be universally provided.

Mrs Sullivan: Maybe we can talk about that at another time. I think it would be an interesting area to follow up.

Hon Ms Lankin: Okay.

Mrs Sullivan: I want to move to the report which was presented to the House today, the Lightman report, which suggests "that the Ministry of Health investigate the quality of medical care delivered to residents in rest homes, and the billing practices of doctors (including `house doctors') who regularly claim for multiple and sequential home visits in rest homes."

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Hon Ms Lankin: I'm sorry, Mrs Sullivan. Could you repeat the first part of that?

Mrs Sullivan: It says the recommendation is, "that the Ministry of Health investigate the quality of medical care delivered...in rest homes, and the billing practices of doctors (including `house doctors') who regularly claim for multiple and sequential home visits in rest homes."

I was interested in this conclusion. Has your ministry done studies it put on the table in front of Dr Lightman that would lead him to that conclusion, and what kind of follow-up would you be making in this area?

Hon Ms Lankin: I have to indicate that I'm at a disadvantage. I was not in this portfolio when the Lightman commission was first commissioned and the ministry interacted with it, so I'm actually not aware of what materials we might have submitted to the Lightman commission for consideration and have only just received the copy of the report as I walked into question period today, so I haven't reviewed any of the recommendations.

I do know the issue of multiple visits being billed under the OHIP system is one we have been looking at with respect to other long-term care facilities, where the practice is the same. I would think it would be important for us, in our review of that which is currently under way, to include the unregulated rest home facilities, because I think it's the same issue at the heart of it.

With respect to the first item, I'll have to respond to you once I've had an opportunity to meet with the ministry and to review the recommendations that are contained in the Lightman report.

Mrs Sullivan: We'd appreciate a follow-up on that as well.

As well in the report, "In an appendix to the report, the commission also suggests that the announced intention of the government of Ontario to eliminate the funding differential between nursing homes and homes for the aged be deferred pending clear evidence of effective accountability to residents in nursing homes."

The announcement you have made previously about eliminating the differential to ensure an equivalent funding for equivalent levels of care, no matter what the location, was one that of course we have bought, and one of the things we have been concerned about was that the transfer for this year has not yet been announced. We wanted to know when it was going to be announced and were quite taken aback with this recommendation, and I wondered if this kind of a recommendation had been on your table prior to this report.

Hon Ms Lankin: No. In fact the first I've heard of it is as you read it to me at this very moment, so it's not formed any part of the discussions with respect to moving to an equalized funding basis. Certainly I'll review the issue, given that it is part of a very important document that has been prepared by the Lightman commission, but I think the method of compensation in the nursing home and homes-for-aged sector that we intend to move to in January of 1993, which is levels-of-care funding, does have in it an assurance of the quality and kind of care that is delivered, because it is moving to a system of evaluating the actual needs of the individual client and of delivering services based on those needs and it is essentially a purchase of service and a level of service related to the amount of money transferred on a patient-by-patient basis. That, along with the ministry's capacity to inspect and investigate, will probably be the answer to address the kinds of concerns that might have been behind that recommendation. However, I should qualify and say that until we've had a chance to look at the report and what prompted that recommendation, I may in fact be wrong in my assertion that it's answered by the levels-of-care funding, but I think it may well be.

Mrs Sullivan: When will you be announcing the transfer for this year to nursing homes?

Hon Ms Lankin: I don't have a date I can tell you at this time.

Mrs Sullivan: Nursing homes generally operate on a January 1 to January 1 basis. We're already at June. They're almost halfway through their fiscal year. Would you like to comment on that?

Hon Ms Lankin: I realize that to be, I think, a significant problem, and I understand your reason for raising it and the nursing home sector's concern, although I think it has been in regular contact with the ministry and understands that we are in fact working on the numbers. We well know that there have been, as a result of the bridge funding announcement made last fall, additional moneys that have been flowing to the nursing home sector -- although they were a month late as well -- and have eased the situation somewhat. I am concerned to get an announcement out as soon as possible. We are actively working on it.

Mrs Sullivan: When you move to level-of-care funding, will you be looking at more than a nursing care criterion?

Hon Ms Lankin: The criterion will be based on the Alberta patient classification system.

Mrs Sullivan: One of the issues that became very clear during the long-term care consultation process was that there was strong feeling in most health care delivery communities and indeed among senior citizens groups and others that the Alberta classification system, which only looks at the nursing care component, was an inadequate measurement device. I wondered if, as a result of that consultation, you were in fact looking to involve another criterion in a level-of-care formula or classification plan.

Hon Ms Lankin: As you may know, there is a pilot project that has been undertaken with respect to the Alberta classification model. If there is any information coming from that pilot project in conjunction with the long-term care consultation remarks that would lead to changes in that policy, those would be forthcoming in our discussions that will be taking place over the next couple of months. We haven't reviewed any information of that sort yet.

Mrs Sullivan: I have about two minutes left, so I'm going to just do one question which we have included in the questions that are written, asking you quite specifically if you will undertake to provide to the critics the reports, the copies of speeches, the documentation or announcements, the press releases and other communication materials on the day they're released, at a time no later than that time when those materials are made available to the public. I think both the opposition critics have found it quite frustrating when it's frequently three or four days subsequent to a report or an announcement or a statement when that material is received. It's very difficult either to be supportive or to be critical when we don't have the material to respond to.

Hon Ms Lankin: I will undertake to do everything within my power to make that happen. My apologies to you if that hasn't been happening. I'm surprised, and perhaps we can talk at a later time about some specific examples, because certainly in my approach to things I have attempted to make sure the opposition critics were informed, if not at the time, in advance, so that you can do your job appropriately. I have no problem with trying to comply with that.

Mrs Sullivan: In the last minute, you have just undergone a reorganization of the ministry. Are you undergoing a new reorganization of the ministry in response to the first reorganization of the ministry, to adapt to new areas of policy development or emphasis? Are you reorganizing the reorganization, is what I'm asking.

Hon Ms Lankin: No, but the reorganization is ongoing at this point in time. What has happened is that the structures and department realignments have taken place on paper, but as we move to fill assistant deputy minister positions -- as you may know, we just recently appointed Ms Jodey Porter to one of the ADM's health strategy positions -- those ADMs who have come into those positions are working to fill the structures beneath them and to bring appropriate staff into the areas. Some of the reorganization of moving policy areas laterally, for example, within the ministry is not yet complete, so it is an ongoing process.

Mrs Sullivan: How are you informing stakeholders of changes as they're made? There's certainly confusion about what is happening in the ministry reorganization now. The sense is that the reorganization structures didn't work and so the reorganization is having to take place again.

Hon Ms Lankin: I'll certainly take up that issue with the deputy. I'm not aware of those concerns. I haven't heard those concerns, and I do travel a lot and talk to stakeholders as well. If there is some indication that's a problem, that there's some confusion, certainly in our correspondence -- we have regular correspondence with various stakeholders over a range of issues -- we can include an update on where the ministry's at with respect to its reorganization.

Mrs Sullivan: Thank you. I've got lots more questions, but we'll wait.

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The Acting Chair (Mr Anthony Perruzza): The Liberal time is, in fact, up. Mr Wilson, you have the floor for 45 minutes, till 5:55.

Mr Jim Wilson (Simcoe West): Minister, when we last spoke in committee -- I guess it was on June 9 -- we ended with a discussion on the involvement of the commercial sector in the delivery of home care services and in-home services. Mrs Sullivan began today where I ended on June 9. I also want to expand on that, because subsequent to our last discussion on this I've met with a number of people involved in the commercial sector.

They tell me they deliver 41% of the home care services in the province, which is much higher than I would have thought. I guess what they point out to me is that they're a little worried. I think you referred to it in your answer to Mrs Sullivan today: that you're reviewing, along with your other cabinet colleagues involved in the redirection of long-term care, the submissions you heard during the consultation process. That's fair ball. We'd expect you to do that. But the commercial operators pointed out to me -- and I see on page 7 of the redirection paper itself that it talks about the goals of the renewed vision in long-term care.

In one section it says, "These new directions in long-term care and support services are designed to meet the following goals." The last goal mentioned is a continued preference for a not-for-profit service delivery system. I'm going to try to give you a sense of why the commercial sector didn't flag that. They didn't really, to try to put it into words, see at the time the redirection and consultations which were taking place on long-term care as a threat to their existence. In retrospect, after the consultations have been completed, I guess they are kicking themselves that they didn't get out during the consultation process and really hammer away at the importance of the commercial sector in long-term care.

They're worried that, if you now review just what you heard during the consultation process, they may have been left out because they missed the boat, as it were, because they didn't take this goal -- as very clearly stated, there's no problem there -- as seriously as they now do. They're very worried about their future existence. Do you want to comment on that?

Hon Ms Lankin: I'd be more than pleased to meet with them if they would like to have a direct meeting to provide their input as well as what I've heard from others during the long-term care redirection consultations. I still continue to meet with groups as they undergo policy considerations and would be pleased to include them in that process if they'd like to contact us.

Mr Jim Wilson: That's very good of you. I think they would very much like to meet with you. I've suggested to them that they meet with you directly, because they're meeting with a number of MPPs and opposition MPPs and I think it would be fair to discuss that with you, because they're very worried about their future.

I also want to bring to your attention an issue that I know you're very much aware of. I've received a number of letters from public health nurses, particularly from the community of Middlesex and London, Ontario, where there have been a number of public health nurses laid off in recent weeks or a number of public health nurses being threatened with layoff. I just want to read to you from a couple of letters from those nurses.

One is from a Ms Annette Sonneveld, president of the Ontario Nurses' Association, Local 36. She writes me asking for my opinion on these layoffs, and she says: "With the current health care dollar crisis and the recognized need for increased community health care, it seems ironic public health nurses are being laid off. I would like to see appropriate funding for public health units. Please let me know your position on this important matter."

We also had a letter from Ms Suzanne Jacques, who is a public health nurse in London, Ontario. She says, "I guess what is most disturbing is the hypocrisy of the layoffs in public health." This is a letter to yourself, Minister, dated May 12, from Ms Jacques.

You said yourself that the emphasis in health care delivery should be in the community sector. More recently, the Orser report, 1992, quotes similar findings that health promotion and disease prevention are our best health care assets and that more financial support should be given in these areas.

Finally, Minister, I want to quote from Dr David Butler-Jones, who's the medical officer of health in Simcoe county. Of course, I represent part of that county here in the Legislature. He writes:

"With the overwhelming evidence and the declared commitment to the shift to prevention, it is difficult to understand why we have not seen a corresponding shift in the funds needed. Public health has consistently been in the forefront of prevention and health promotion, community-based programs and developing the concept and application of determinants of health."

Minister, I just wondered if you wanted to take a moment to comment on those concerns that have been brought to my attention.

Hon Ms Lankin: The spirit expressed within those concerns of the importance of shifting the emphasis to community health, to public health, are concerns I agree with. In terms of the funding of the public health units this year, if you look through the estimates material you'll see that we have in fact increased the funding of public health at a level beyond the overall growth rate in ministry spending, which is 2%. That does show where we are restricting funding in certain areas and allowing funding to grow beyond overall ministry averages in other areas. Some indication of the priority is that we have provided 100% dollars for new health promotion programs in the mandatory programs area to the public health units.

There are certain areas in their ODOEs and others where we have seen, in the way they're applying the increase, that they are cutting back in those areas, as are hospitals, as is the ministry, as is every public service area in terms of trying to get better efficiency out of the dollars they do have.

I know there have been a number of units where there have been proposed layoffs and where the unions and the employers have sat down and have worked through alternative mechanisms to achieve cost efficiencies in the administration of the health unit that have avoided those layoffs. I would hope that is a process that would be happening in the areas you have raised the concerns from. I am sure that, if I have not already, I would be responding urging the parties to undertake what has happened in other areas.

The chief medical officer of health has worked with other medical officers of health to help them take that kind of approach in sitting down with their staff, their unions, to look for other ways of saving money. I hope what is happening with the increase of moneys provided to the public health units and with the restructuring and reorganizing is that more money is actually going to support the areas those letters raise concerns about.

I understand the point to be made, that if there are layoffs in certain areas it would appear to be in direct contradiction to delivering more services. I can't speak to the specific organization of a health unit and whether the restructuring that needs to go on requires these layoffs, but the general comments I've made I think would indicate that we have provided increased support to health promotion and community-based public health programs this year at a rate beyond the overall growth rate of the ministry.

Mr Jim Wilson: Does your ministry provide specific guidelines for public health units to deal with this? I've met with a couple of public health units where it seems to me they've been most creative and tried to avoid layoffs but are telling me that layoffs are inevitable and that key areas of prevention and public education will be the first to suffer. They feel very much stretched to the limit. What precise assistance does the Ministry of Health give to these public health units?

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Hon Ms Lankin: Certainly in some specific situations the chief medical officer of health, who has the overall ministry responsibility for the public health program, official local health agencies, has met with local medical officers of health and has had discussions which have led to more creative problem-solving going on in the health units, and I would think that would extend across most of the health units.

I point out that in the estimates the transfers to local health agencies increase year over year; it's almost 4% this year to public health units in terms of ministry funding.

One of the areas some of the local health agencies face is the complication between provincial ministry funding and municipal funding because it is a jointly funded program, not in all jurisdictions but in a number of them. I think it is another example of an area that we may want to take a look at as we move through the process of disentanglement, because the nature of the programs are so essential that the kind of differential situation of provincial and municipal funding mechanisms often leaves the delivery of those services in a precarious situation. That's why the ministry has moved to mandated programs where there has been 100% funding for those programs. But I recognize that it's a more complicated problem than simply continuing to have mandated programs, because some of the other public health programs that are on shared cost are equally important. I think it's an area we should flag for disentanglement discussions as they continue.

Mr Jim Wilson: I'm pleased to hear your response, because I think you're right. Very often when these budgetary decisions are left to county governments and municipal politicians they may not have access -- I know in my area I've done my best to try to educate councillors -- to the knowledge we have in terms of realizing the importance of these services, so they do tend to get the axe fairly quickly in the budget procedure and it is disturbing. I received a rather disturbing phone call from a constituent this morning, a gentleman who lives in Wasaga Beach. I want to take this opportunity to raise the issue with you. The gentleman told me he is to have knee surgery at the Royal Victoria Hospital over in Barrie, which is about a 50-minute to an hour drive from Wasaga Beach, as you know. The hospital has told him that following his surgery he can't stay there because they don't have enough funding and they don't have a bed for him. He'll have afternoon surgery and in the evening he'll have to go somewhere. Their new policy is that since he can't stay at the hospital because it can't afford to keep him, he's either to stay with family and friends in Barrie -- he doesn't have any in Barrie -- or they've given him a list of hotels the hospital has recently made preferred-rate arrangements with.

I find this rather disturbing, as did my constituent, I can assure you, that the public system can no longer really look after his needs. It raised a number of questions for me. The concern is that the hospital wants him nearby after surgery in case he has excessive bleeding or complications, but there's no room in the inn. They've gone as far as a preferred rate hotel list to give to their patients, and I've seen the list. They're not paying for the hotel. I think it's a very disturbing policy that the hospital tells me has been forced upon it. They have no choice. It raises questions of whether you feel this is fair and appropriate. How would a person without the means to stay in a hotel nearby be able to do that? The hospital, I assure you, is rigid in its decision and did not want to take this decision. I just wonder if you have any comments on that rather disturbing situation.

Hon Ms Lankin: I'd certainly appreciate the opportunity to look into it. This is the first I've heard of this situation. I think the increased use of day surgery is an appropriate direction in the province and would support the direction of hospitals with respect to that. There are hospitals that have in fact over many years argued that the hospital bed portion of hospital services should not be part of the insured services and that hospitals should be allowed to charge for hotel services. I think some hospitals are taking steps to underline that point. But as I've indicated, I'm not aware of the specifics. I think the concerns you raise about how individuals who need to travel for such access to medical services and surgical services in this circumstance and how individuals without the financial means to meet those obligations will fare if this becomes a concrete policy of hospitals is reasonable for us to look at.

One of the other things I would suggest, however, is that what we're trying to build is a link between day surgery programs in hospitals and acute care home care programs. I'm not sure in this circumstance why the hospital would suggest that the individual needs to stay in close proximity to the hospital if what he requires is acute care follow-up, which may well be able to be provided in the individual's home. I don't know the circumstances of this individual.

Mr Jim Wilson: Right now, I won't get into the lack of the full range of services in my riding for acute care services in the home. It is a real problem and I think I've written to you in the past. It's something I know you're trying to address.

I was shocked by this phone call and this scenario, because it's in Mr Wessenger's riding and the gentleman's from my riding. I guess when it hits home, it hits hardest. Surely to goodness your ministry would know this was coming, because have we not had similar cases with regional cancer centres where there's no room at the inn and people have to stay near those centres?

I know when I was first elected, I had the case of a family who had to take an apartment in Toronto with extreme hardship. We managed to do a community fund-raiser for them to have that apartment for some six months. That was one situation that pre-existed your coming to office, but now it's happening even with what should be relatively easy-to-handle day surgery situations.

I'll take you at your word that you'll look into it. I'll be sure to write this up a little better for you to look into, and I appreciate your doing that.

Hon Ms Lankin: I would appreciate that. I might also take the opportunity when you provide me with that to share that with our federal Minister of Health. I just spent several days last week in a meeting where I felt that the federal government's desire to discuss flexibility with respect to the interpretation of the principles of the Canada Health Act was disturbing. I felt we should be talking about appropriateness of services and looking at how we get at inefficiencies that are inappropriate or procedures that don't produce good health outcomes as opposed to getting at flexibility around the interpretation of universality and comprehensiveness etc.

I know there are some differing opinions among provinces with respect to that. Some provinces would like a greater latitude to be able to interpret, for example, the universality principle of health insurance and hospital services as not applying to the hotel portion of the hospital bed service. I think it raises very important implications for us with respect to the future nature of the medicare system.

Mr Jim Wilson: I agree and I would urge you to have those discussions and leanings on the federal minister quickly, because I suspect after about June 1993 he won't be the Minister of Health any more. You may even be dealing with your own colleagues up there.

Before Mrs Marland asks a couple of questions, I do have one more concerning radiation therapists. It appears from mail I'm getting from therapists across Ontario that they seem rather angered by the government's decision, which they describe as arbitrary, to relocate all education programs for radiation therapists to a new program, which I believe is to be established at the Michener Institute.

I'll just quote from a letter that puts it into context. It's a letter that was sent to you on June 15 of this year from T.J.D. West of Don Mills, Ontario, and he or she writes:

"It is regrettable that you appear to be unwilling to meet with the representatives of our professional organization to discuss other more efficient and cost-effective ways of providing for the education for radiation therapists within Ontario. This is inconsistent with the stated philosophy of your government, which claims that it is committed to the consultation process. It would appear that your ministry is not prepared to listen to the proposals of those who actually provide the radiation therapy, preferring instead to take advice from senior Ministry of Health staff, representatives of management of the two provincial cancer agencies and the Michener Institute."

Minister, are you aware of the issue and would you like to perhaps explain the reasons for this reallocation?

Hon Ms Lankin: I can indicate to you that I don't have a great deal of information on this particular issue. I'm certainly willing to have a member of my staff look into this and meet with the individuals, if that would be of any assistance.

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Mr Jim Wilson: Apparently a decision's already been made by you or your ministry. If I went on to read the rest of the letter, the tone of the letter isn't very pleasant. Obviously, there's quite a bit of frustration expressed. Would you undertake to meet with the concerned group yourself?

Hon Ms Lankin: I would certainly undertake to have a member of staff meet with them first to go through the issue and find out what its status is, only because I don't have a lot of background knowledge on the issue.

I certainly know we have been attempting to increase the number of radiation therapists trained in the province to meet a shortfall and concern around growing waiting lists for access to radiation therapy and that this issue has been managed over the course of a number of years within the ministry to try to meet those needs.

I'm sorry I don't have knowledge at my fingertips of the actual decision or circumstances that gave rise to the letter you have. I've done pretty well thus far in terms of your questions, but there's a lot that goes on within the ministry that I don't know on a detailed level.

Mr Jim Wilson: And I appreciate that, Minister.

Hon Ms Lankin: I could try to have some more work done on that and have a member of my staff or ministry meet with them in a preliminary fashion and from that see what follow-up is required.

Mr Jim Wilson: I appreciate that, Minister, but the concern is not only from individual radiation therapists but also from the Ontario Association of Medical Radiation Technologists. I'll leave that with you and be sure to send it your way. I believe Mrs Marland has some questions she'd like to ask.

Mrs Margaret Marland (Mississauga South): At the outset I would like to thank the Health critic for our caucus for allowing me a little time. I think what I'll do, Minister, if it's okay with you, is put before you a number of things, and if you don't get time to respond to them today, could I ask that I could have a written response in the future, only because we're now so short of time?

I want to read into the record a letter which is a copy of hundreds, maybe thousands, I'm sure you've received. This is on the letterhead of a school in my riding, St James School, over the signature of R. J. Kraft, the principal, and it was sent to you in May:

"Dear Minister: I am writing to you as principal of St James School in support of the Heart and Stroke Foundation of Ontario's tobacco advocacy efforts. Our school, representing 160 students, supports the Ontario campaign for action on tobacco and the coalition's objective to `Give Kids a Chance.' The campaign's eight prescriptions for health to avoid addiction to tobacco industry products will have a significant effect in limiting children's access to tobacco.

"We are concerned in all of our communities that children are having access to tobacco products. Research shows us that coronary heart disease accounts for 18,000 deaths each year, in which 6,000 of these deaths are attributed to tobacco use. We must prevent our children from becoming tobacco users and eventually becoming one of these statistics in their adult years. If we are to curb this tobacco-related epidemic, we must pay special attention to our children and adolescents as we now do with access to alcohol and drugs.

"We commend you on initiating a comprehensive tobacco strategy for Ontario, but urge you to issue an enhanced regulatory framework for tobacco control and introduce legislation that embraces the eight-prescription plan. If this is done with the seriousness it demands, your ministry will go down in history as the government who truly stood with the health care community and its respective organizations in the fight against the leading cause of preventable death and disability in Ontario. We look forward to a favourable reply and your support for the `Give Kids a Chance' campaign."

I have the identical letter from Whiteoaks Public School in my riding, over the signature of Mr P. Guillemette. I also have it from the assistant professor of the department of paediatrics, Dr Ursula Tuor, at the Hospital for Sick Children, and Mr D. Wilson, the principal of Homelands Senior Public School in Mississauga.

I also want to read you another letter that covers a subject I know you will be familiar with, a letter over the signature of Dr John H. Barker of the Barker medical clinic, also in my riding:

"Dear Margaret: For the past 20 years, I have witnessed in my own medical practice the benefits of supplementing the diet of thousands of seniors with vitamin C and other nutrients. This inexpensive means of boosting resistance to disease has been very successful. It is used by a growing number of physicians and by millions of people, despite lagging support by a doubting establishment.

"It would be a backward step for the government of Ontario to remove vitamin C and other vitamins from the drug benefit list. Our older citizens would have the most to lose by such a negative health measure.

"In fairness, the government may be unaware of the vital importance of optimum nutrition, and particularly vitamin C, in enhancing the power of our body's immune system. The medical profession has itself been almost totally unaware of these important functions of vitamin C and other anti-oxidant nutrients in reducing risk in cancer and cardiovascular disease. Increasing evidence supporting this is now appearing almost daily.

"Thus, the new drug benefit proposal to remove these very items from the list is certainly not in keeping with the government's desire to reduce health costs by promoting prevention of disease. What an opportunity there is here for much-needed leadership in disease prevention. Lack of vision in this issue will have costly consequences both in dollars and disease.

"I'm enclosing some articles to support the above statements" -- then there's a personal comment I don't think you're interested in. I would like to give you, Minister, the accompanying information and Dr Barker's letter. If I could request a response from you to that, I would appreciate it.

The other subject is still on the changes to the Ontario drug benefit plan, and these are some concerns that were brought to me by a man in my riding who has been a practising pharmacist for 45 years. I'm just going to list the concerns and the points he makes.

He has a general concern about drugs being removed from the formulary: "The public perception is that when a drug is removed from the formulary, it is of no benefit, but this is not true. For example" -- interestingly enough, he talks about vitamins -- "vitamins are very effective and inexpensive -- example, $10 per month -- compared to other expensive drugs of questionable efficiency, such as Deprenyl, used by Parkinson's patients, which costs $300 a month. The only vitamins retained on the formulary are B12 shots and niacin.

"Cough and cold therapy is wiped out. The suggestion is that nothing works. The logical switch would be to antibiotics, which are still covered by the plan, but antibiotics are expensive, can lead to serious secondary infections, and their overuse can result in the drugs losing their effectiveness, which is dangerous when the need comes to fight a very serious infection. Now the only cough syrups covered will be those with codeine, which require a doctor's prescription and bring with their use a risk of addiction.

"Antihistamines are removed. This could lead to the use of more potent drugs for allergic reactions.

"Anti-spasmodics: Some have been removed, and this could lead to patients being switched to more expensive, but not necessarily more effective, treatment.

"Quinine: commonly prescribed for leg cramps," and there's no alternative. I can vouch for the fact that quinine works for that problem.

"PEG-Electrolytes: essential pre-X-ray treatment; the alternative is castor oil." How regressive.

"Gravol and its generics: The suggestion must be that seniors don't get nauseated. The alternative now covered is a new anti-nauseant at a cost of (48$" -- per what?

"Sun screens: Seniors are much more susceptible to skin cancers than middle-aged and younger persons.

"Ointment and lotion vehicles are being removed from the formulary, yet skin specialists require them as a basis for prescription treatments. This section is most confusing."

He has a concern regarding process. I should tell you that this pharmacist is Ron Purdy; I didn't give his name at the beginning. He owns a number of small drugstores.

The Ontario Pharmacists' Association received a letter regarding the proposed changes on May 29. Mr Purdy received his copy of that letter from the OPA on June 5, which is a fair turnaround from May 29, but the deadline for a response was June 10, 1992. "So much for consultation" is his concern.

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Then there's the question of money saved. The money saved is $100 million annually according to the ministry. Mr Purdy points out that this is not even the cost of one electron microscope. "The government is nickel and diming the pharmaceutical industry and the patients of the Ontario drug benefit plan."

I'm happy to give you a copy of this so you could respond in writing to those points as well.

The other general comment I want to make -- and I do want to give the floor back to the critic -- is that I don't know how much time has really been spent discussing dispensing fees. They were an issue long before you were the minister or your party was in government, Minister, but in fairness, the variance in dispensing fees has to be addressed for all people who require prescription medicines.

Some people are in a position to shop around and find the big stores or whoever has the volume that may lead to a reduced dispensing fee, but in small communities like the one my critic represents, for example, they probably don't have the benefit of the large multinational chains that can reduce prescription fees based on their volume. The small drugstore operator has to upfront the major capital cost of having all the drugs and medications in stock, on supply, so when those sick persons need them, when they come in with a prescription that day, their costs are different from the person who has the advantage of volume buying and volume storage space compared to a small individual store. That is something you might like to address.

Hon Ms Lankin: You're talking about dispensing fees for people who are not covered by the Ontario drug benefit program, the general consumer?

Mrs Marland: Yes, the general consumer and the overall discrepancy between the different levels of dispensing fees. I'm quite happy to have these answers in writing if you have more questions.

Hon Ms Lankin: I would be pleased to answer them at this point in time as you've tabled them.

Mrs Marland: Excuse me, Minister, the critic has more questions, so in fairness to him I'd be happy to have your answers in writing.

Hon Ms Lankin: I'll keep my answers very brief, but I would like to give them verbally. It's a tremendous amount of work to provide detailed written responses, and in these areas I think I can provide them in fairly short order.

In response to the first letter you read into the record on the tobacco program, I appreciate the kind of response we're getting from schools across the province and others who are involved in this campaign. I can indicate to you that in addition to the kind of funding announcements we have made on health promotion programs targeted at tobacco and at children, we are in the process of developing a regulatory framework to suggest to the Legislature. That work is ongoing, so I hope you will be supportive when we come forward with that. I think the community, whose concerns you have brought forward, will in fact be supportive.

On the issue of the Ontario drug benefit program, specifically with respect to over-the-counter products that have been proposed for delisting from coverage on the Ontario drug benefit program, that is a follow-up to the recommendation of the Lowy commission. The recommendations have gone through extensive review and have been promulgated by the Drug Quality and Therapeutics Committee, which you know is a scientific community.

The suggestion that the perception is that if these are delisted it means they don't work is something we should take seriously. We should try to deal with that perception, because that's not necessarily the reason for taking something off the program. In some cases it may be of questionable value and that reason should be spelled out, but in certain situations we have had products that have crept into coverage under the program which in fact don't really fall within the criterion of "medically necessary." They may well fall within the very important criteria you focus on in terms of disease prevention or health promotion, but the program itself -- and it has been growing in cost -- is really designed to provide seniors and those persons with limited financial ability the assurance of access to critical drugs that are medically necessary in those times of illness.

In fact, the expansion of the program beyond that is one that jeopardizes our ability to keep the main goal in focus. That has been one of the reasons for the Lowy review and others that have suggested we need to focus and to keep the program clear. I understand the concerns on things like sun screens, which are preventive and which are helpful, but they're not exactly the kind of thing that was envisioned when ODB was created in terms of a program to provide access to those critically medically necessary drugs to keep people's health status when they are suffering from illnesses.

In terms of the consultation, I would add that although the time period for response was tight, we did provide an opportunity for people to come in to a central meeting to consult with representatives of the profession as well as to try and have a dialogue and provide them with more background information.

On the issue of dispensing fees, I appreciate the point you raised. There are general discussions taking place with the industry by the drug reform secretariat over the course of the next period of time around the structuring of dispensing fees and the issue of markup versus dispensing fees. It may well be that this will lead to some different considerations with respect to access by the general public, although I would point out that where this is a private sector commercial operation, the entrepreneurial differences between pharmacists' companies and delivery mechanisms will probably lead, for the general public, to those kinds of differentials. But we will take that into consideration as we meet with them to express your concerns.

Mrs Marland: Do you want to do that in writing after your staff has reviewed the material?

Hon Ms Lankin: I think I spoke to that in terms of the issue of over-the-counter drugs and the response that these have been reviewed by the Drug Quality and Therapeutics Committee. I will undertake to provide you and all members of the House with a detailed list when we finally make the decisions, with respect to the list that has been out under consultation, of the reasons why the status of each and every one of the products was changed.

Mrs Marland: Could I ask for a response to the submission that has the argument in support of this preventive health direction, which is what I think you want to encourage, preventive health?

Hon Ms Lankin: Certainly.

The Chair: Mrs Marland, thank you. Mr Wilson's been most patient.

Mrs Marland: I was just asking if I could have that.

The Chair: I know you were, Mrs Marland, but I was recognizing Mr Wilson.

Mr Jim Wilson: Mrs Marland, I'm hopeful the minister will undertake to provide some of that in writing in a more thorough way.

Last Thursday I had the opportunity to tour our health facilities in Peterborough. I went to both St Joseph's and the Civic Hospital. On my rounds, I met a very interesting lady by the name of Mrs Jean Gunn, who is the president of A Closer Look X-Ray Inc in Peterborough.

It once again hit home to me that something's going on in your ministry with regard to commercial providers of health care services, or private sector providers. Mrs Gunn tells me that late last year her licence and authority to provide a number of necessary in-home X-ray services was drastically reduced. In fact, there was a decision made by your ministry that she had to discontinue providing a number of valuable in-home services, including the fact that she went into a number of local seniors' homes, rest homes and anywhere she was called in -- on doctor's orders, of course, as is required.

I wanted to ask you whether it makes any sense to you that Mrs Gunn can no longer provide her service, because your ministry has not provided good reasons for discontinuing her authority. I think the figures in the local paper that day were that as a result of her being forced to withdraw her services, the Ministry of Health is now paying an extra $60,000 a year transporting patients by ambulance to either the Civic Hospital or St Joseph's for X-rays. Do you have any comment on that? It should have been brought to your attention, because I know one of your senior ministry officials met with Mrs Gunn earlier this year in an attempt to address her concerns, really in vain as far as Mrs Gunn was concerned.

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Hon Ms Lankin: I appreciate your opinion that it should have been brought to my attention. It has not been brought to my attention, I'm not aware of the case, and I wouldn't be prepared to comment on a specific provider's interaction with the ministry around the status of her licence and what she or is not able to provide. I'll certainly look into the issue you have raised, and in particular the appropriate or inappropriate use of an ambulance to transport non-critical patients for the purpose of obtaining X-rays.

Mr Jim Wilson: I'll just give you a little help there. It was Dr MacMillan who met with Mrs Gunn, so you shouldn't have too far to ask what's going on.

Minister, also on Monday, June 22 -- Monday last -- I met with a committee of independent pharmacists who have concerns regarding your government's intention of banning the sale of tobacco products in pharmacies. It really has reference to Mrs Marland's comments and concerns. I think what the independent pharmacists would like to get across to you is that they very much feel that your government wants to ban the sale of tobacco products in pharmacies but not across the board, ie, that they would be put at a competitive disadvantage if the government were to follow up on what I know the Ontario College of Pharmacists has recommended. They've had a number of their members now elected to the College of Pharmacists, and they're working to have that decision of the college overturned.

I guess my question is twofold, Minister: Are there plans on the table to ban the sale of tobacco products in pharmacies? Second, would this be done by legislation, or do you have the power to do that by regulation?

Hon Ms Lankin: As I have indicated directly to the Ontario Pharmacists' Association at its annual meeting, I appreciate the kinds of concerns that have been raised by certain pharmacy owners with respect to this issue. I equally appreciate the work the college did that led it to develop and propose this recommendation. It is an issue that is under active consideration, and as I have indicated, from a health perspective it is one I personally am supportive of government giving consideration to.

Mr Jim Wilson: In terms of banning it outright just in pharmacies, do you not find that discriminatory? For instance, when I worked for the federal government, we looked at sector-by-sector bans. If you haven't already, I think you may want to seek advice on whether that be constitutional. I would think any pharmacist who wants to sell a legal product and is put at a competitive disadvantage vis-à-vis the smoke store or grocery store down the street would have an excellent constitutional case. Have you sought advice or received advice on that from your ministry officials?

Hon Ms Lankin: As proposals with respect to any regulatory framework are being developed, legal counsel does review and provide advice on that, and I'm sure I will receive a full range of advice with respect to that proposal which has been put forward by the College of Pharmacists.

Mr Jim Wilson: And that would be through regulation, Minister?

Hon Ms Lankin: I'm sorry, in terms of the technicalities of whether it would be regulation or legislation I can't answer at this point in time. We haven't got so far as to actually draft various provisions as we're still working on the policy decision-making.

Mr Jim Wilson: Would you get back to me, just on the question of authority, whether it would be a matter that would come before the Legislature or whether it would be done through a change in the regulations?

Hon Ms Lankin: I can indicate to you that it is my intention, if I receive approval through the various cabinet policy processes, to bring forward legislation that would include both legislation and regulation, and at that point in time when I table that we can specifically look as to whether or not a policy decision has been made to support the college's recommendation to us on the ban of sale of cigarettes or tobacco products in pharmacies and what form that takes, either legislation or regulation.

Mr Jim Wilson: Thank you, Minister. Mr Chairman, I'd like to give the last word to my colleague Mrs Marland.

Mrs Marland: I have one further letter on the Give Kids a Chance campaign, which is over the signature of Hardy Limeback, who is an associate professor, department of preventive dentistry, at the faculty of dentistry, University of Toronto. He is a University of Toronto researcher working in the cardiovascular health field. I just add it to the other letters on that subject that I will be giving you a copy of. Most of them have already been addressed to you personally.

Hon Ms Lankin: Okay. I thank you and I appreciate that. Following up on your colleague's questions, I would just point out that individuals who are part of this campaign have been voicing very loud support for a regulatory framework that would prohibit access to tobacco products in certain venues and certainly limit access by youth to tobacco products, so I think there is a range of growing public opinion in support of a tougher regulatory framework.

Mrs Marland: What does it mean, "in certain venues"?

Hon Ms Lankin: For example, the question your colleague just raised with respect to the sale of tobacco products in pharmacies or other health care facilities; hospitals, for example. Those recommendations have been made to government and they're under active consideration.

The Chair: Although there remain 49 minutes in order to complete our Health estimates, I believe there is unanimous consent from the committee to call the votes at this time. Is that agreed?

Interjection.

The Chair: Yes, I'm going to give an opportunity, Mrs Sullivan. I would like to proceed through the votes on the off chance that we're called to the House. When one looks at the clock, one realizes that we may not be able to complete today by virtue of being called to the House. I'm anxious to get the votes portion done, and then the Chair will permit some summary comments by the two critics very briefly, if they so choose.

Mr Bisson: Agreed.

The Chair: You don't have to agree; that's my ruling.

Votes 2001 to 2003, inclusive, agreed to.

The Chair: Shall the 1992-93 annual estimates of the Ministry of Health be reported to the House?

Agreed to.

The Chair: Having completed our Health estimates, perhaps Mrs Sullivan wants to make a brief statement, then Mr Wilson.

Mrs Sullivan: I think as we've gone through this estimates process that it's been very clear to the minister that both of the opposition parties are concerned about the approaches being taken to restructuring in health care in terms of the delivery and that have been underlying some of the unease that's being expressed to us about changes that are being made.

Certainly while changes to health care delivery do bring unease, of course they also bring new opportunities. One of the things that is very clear to me is that people want to be assured that any changes made won't be arbitrary, that there will be adequate consultation, that the change will be based on adequate research and a broad-based policy development and a full analysis of alternatives. I think that over the past year there have been some concerns raised in all of those areas. I think, by example, of the Ontario drug benefit program, where some drugs were removed from the formulary without consultation or, apparently, understanding of the use of those drugs.

Interjection.

Mrs Sullivan: I know; I'm hurrying up. We look again at the ODB program and we see 14 days allowed for consultation on removal of over-the-counters. We see similar problems because of lack of consultation with medical laboratories in terms of changes. Although latterly fixed up, none the less that consultative process was flawed. The Public Hospitals Act, same thing: difficulty in the consultative process, where flaws have to be fixed up. As long as that kind of flaw is seen, there is going to be continuing unease and continuing questions asked about the entire approach and policy development in the ministry. That's what our questions underlined: how policies are being made, who's being talked to, who the stakeholders are, what analysis is underneath. That's the kind of information we need.

1800

Mr Jim Wilson: I want to very briefly thank the minister and her senior officials and assistants. It was my first opportunity to go through an estimates process and I enjoyed it immensely.

I think a number of themes come out of it. One, I would express in a polite way my disappointment that I still -- and maybe it's my own deficiency -- don't have a tremendous sense that there is a management plan in place, although I have a good sense as a result of the responses from the minister that she is working very hard. I note that she certainly provided us with timely information and, I think, responses many times that were much appreciated and as thorough as one can expect from a fellow human being who has to remember so much information. I respect you for that, Minister.

I want to make a plug that perhaps, if we have the privilege of doing estimates again, you may want to clear your schedule for several weeks and ensure you're able to attend every day. I know you had to be in Ottawa, but we wasted about an hour yesterday arguing over your attendance and I think that was unfortunate because we had many more issues we wanted to raise.

Finally, Minister, if I may say, health care would be enhanced greatly in Simcoe county if you would give approval soon to the redevelopment of the Collingwood General and Marine Hospital, the Royal Victoria Hospital in Barrie, Orillia Soldiers' Memorial Hospital and, of course, Stevenson Memorial Hospital in Alliston, where I was born.

I thank you for your patience with us and the answers you provided. I am looking forward to working with you.

Hon Ms Lankin: Let me say that this also is my first experience with estimates, and my apologies for the confusion that apparently took place yesterday around my attendance. As you are aware now, I guess latterly, I was attending the national physicians' conference and was representing all provincial and territorial ministers of health. It was an important venture to be involved in.

I appreciate the nature of the concerns that underline the kind of questions raised by both opposition critics. I think there is an instructive element to the questions that has been helpful to me as well, in terms of understanding where perhaps we need to spend more attention and understanding where perhaps I need to communicate better the intentions of the government so they are more apparent.

I understand the concerns particularly around matters of consultation and strive to improve the way we work with all the stakeholders, but I point out that in a number of areas it has been viewed, given the nature of the difficult fiscal circumstances we face and the need to move in certain areas to contain costs while we work with the parties in a collaborative way to try to reform and restructure to build a better health care system, that certain steps we felt had to be taken in the context of fiscal and budgetary decisions that didn't allow for the fullest consultation. I know that has caused great concern to a small number of stakeholders who experienced the results of that. I have apologized to them and hope to work with them more collaboratively in the future.

I look forward to continuing my work with the two opposition critics and the members of the government on these very important issues.

The Chair: Thank you, Madam Minister. I would like to thank the deputy and assistant deputy ministers for their participation as well. I also would like to suggest that it would have been far more helpful had the ministry been able to distil the large number of questions and separate those that required time and those that did not.

An incident occurred yesterday which, as the Chair, I will be bringing to the attention of the Speaker quite independently, as I feel that the privileges of one of the members may have been breached. As the Chair's initiative, I will be raising that directly with the Speaker. I just hope all members are treated fairly and equitably in the process of estimates so they can complete their work in accordance with the spirit and intent of our standing orders.

Having said that, I have two items to report to the committee. If the Legislative Assembly agrees to meet next week, according to the House rules we will be reconvening on Tuesday and we will instruct our clerk to so advise the Ministry of Education and the appropriate critics to be prepared. Also, should we receive permission from the House leaders to meet through the summer, we will reconvene then. If not, then we will reconvene when the House reconvenes in September.

There's no other business.

Mr Bisson: I have a question. Both points that you raised with regard to the times for estimates are dependent on agreement with the House leaders, I take it.

The Chair: That's what I indicated. The first is that if it is the wishes of the House that we sit next week, I am just advising the committee that we will.

There being no further business, this meeting stands adjourned until Tuesday next.

The committee adjourned at 1806.