CONTENTS
Wednesday 21 July 1993
Ministry of Health
Hon Ruth Grier, Minister
STANDING COMMITTEE ON ESTIMATES
*Chair / Président: Jackson, Cameron (Burlington South/-Sud PC)
Vice-Chair / Vice-Présidente: Arnott, Ted (Wellington PC)
*Abel, Donald (Wentworth North/-Nord ND
Bisson, Gilles (Cochrane South/-Sud N)
*Carr, Gary (Oakville South/-Sud PC)
Elston, Murray J. (Bruce L)
*Haeck, Christel (St Catharines-Brock ND)
Jamison, Norm (Norfolk ND)
Lessard, Wayne (Windsor-Walkerville ND)
Mahoney, Steven W. (Mississauga West/-Ouest L)
Ramsay, David (Timiskaming L)
*Wiseman, Jim (Durham West/-Ouest ND)
*In attendance / présents
Substitutions present/ Membres remplaçants présents:
Mathyssen, Irene (Middlesex ND) for Mr Bisson
O'Connor, Larry (Durham-York ND) for Mr Lessard
Sullivan, Barbara (Halton Centre L) for Mr Mahoney
Wessenger, Paul (Simcoe Centre ND) for Mr Jamison
Wilson, Jim (Simcoe West/-Ouest PC) for Mr Arnott
Clerk / Greffière: Grannum, Tonia
The committee met at 1539 in room 151.
The Chair (Mr Cameron Jackson): I'd like to call the committee to order to consider the estimates of the Ministry of Health.
Mr Jim Wiseman (Durham West): Mr Chairman, before we begin --
The Chair: Is it a point of order?
Mr Wiseman: It's a point of order.
The Chair: What is your point of order?
Mr Wiseman: Under section 117(a) of the standing orders, page 84, it says that, "A majority of the members of a standing...committee, including the Chair, shall constitute a quorum."
Yesterday, with all six members of the New Democrats here and yourself in the Chair, you ruled that there was no quorum and you ruled --
The Chair: I'm sorry, Mr Wiseman, on that point of order, I can't really accept a point of order on the activities of the committee that occurred yesterday, when we have the Ministry of Health before us.
Mr Donald Abel (Wentworth North): Sure you can.
The Chair: I have a motion on the floor at the moment, which is to consider the estimates of the Ministry of Health.
Mr Wiseman: I therefore challenge that ruling.
Mr Abel: We know the rules, too, Cam. Give us a break.
The Chair: We have a motion on the floor and --
Mr Wiseman: I believe that a challenge to the Chair has to be voted on.
The Chair: I'll have to inquire if I can accept a motion to challenge a decision of the Chair when there's a motion on the floor, if you'll give me a moment. The Chair would like to call a brief recess of five minutes.
The committee recessed from 1541 to 1547.
The Chair: Thank you for your indulgence and patience while we sought some further clarification from the clerk's office.
As I understand it, we have a motion on the floor to proceed with the estimates of the Ministry of Health. Subsequent to that, I recognized Mr Wiseman. I assisted him in framing it as a point of order. He then stated his point of order, which was his concern about the manner in which an objection raised yesterday was handled by this committee. My ruling was that it was not a point of order, given that we were proceeding with these estimates at this time. He is now challenging that ruling, which was to rule his point of order as not being a valid point of order before this committee in the midst of its estimates.
It is the decision of the Chair to recognize his subsequent request to challenge that and we'll proceed with a vote on that directly. That matter will be referred to the Speaker for him to deal with, to be heard tomorrow by the Speaker. The committee would then be prepared to proceed with the business of the day.
Mrs Barbara Sullivan (Halton Centre): A point of order, Mr Chairman.
The Chair: I can't deal with a second point of order when I have a motion to challenge the Chair. That's not subject to debate. Are we prepared to vote?
Mrs Sullivan: I would request a 20-minute recess.
The Chair: Thank you. When the vote is called, there is a request for a 20-minute recess for you to assemble your members. This committee is adjourned for 20 minutes.
The committee recessed from 1549 to 1607.
The Chair: We are called to order. Shall the ruling of the Chair be sustained?
All those in favour?
Ayes
Carr, Sullivan, Wilson (Simcoe West).
The Chair: Those opposed?
Nays
Abel, Haeck, Mathyssen, O'Connor, Wessenger, Wiseman.
The motion is defeated. Therefore, the clerk will notify the Speaker and that appeal will be heard tomorrow in the House.
Madam Minister, are you prepared to proceed? You have the floor.
Mr Wiseman: I understand that there's --
The Chair: Mr Wiseman, the minister has the floor.
Mr Wiseman: I believe we need a motion to proceed.
The Chair: I have given the floor to the minister to proceed with the estimates.
Mr Wiseman: But I believe that is a procedural error, Mr Chair.
The Chair: Mr Wiseman, I have recognized the minister to proceed. We had a motion on the floor to proceed with estimates and we are now proceeding with the estimates.
Mr Wiseman: We need to have a vote to proceed with estimates.
The Chair: I'm not engaging in a dialogue, Mr Wiseman. I have recognized the minister. Welcome, Minister. Please proceed with your estimates. You have just shy of 10 hours remaining for the estimates.
Mr Wiseman: With all due respect, Mr Chair --
The Chair: Mr Wiseman, you will be called out of order a second time.
Mr Wiseman: I would challenge that, Mr Chair.
The Chair: I haven't called you out of order. I said you will be. You are interrupting your own Minister of Health. I have recognized the minister and her clock is running. She has up to 30 minutes.
MINISTRY OF HEALTH
Hon Ruth Grier (Minister of Health): Mr Chairman and members of the committee, I'm pleased to appear here to discuss this year's estimates for the Ministry of Health. I know that the estimates process is both a healthy and a democratic exercise. I already have a flavour that with this committee that is indeed what it will be, and I hope we can make this and the following sessions as useful and as productive as possible.
It's hard in 30 minutes to cover all the activities of the Ministry of Health, but I thought what I would do would be to begin by reporting to you on the status of some of our programs and activities and provide you with an outline of where we stand on the major issues in provincial health care today. In particular, I want to talk about the government's strategy for managing the health care system during this difficult economic period, as well as about the many reforms that are, in most cases, well under way.
Ontario continues to enjoy one of the best health care systems in the world. The fact is that the system works well for the vast majority of people in Ontario. Most citizens get the health services they need, where they need them and when they need them. However, there are many areas where we can do things better, more efficiently and more cost-effectively.
In addition, the traditional health care system, with its emphasis on physician services and acute care hospital-based services, is being threatened by a variety of social, political, philosophical and economic forces. These forces threaten the five principles under which the system operates: universality, accessability, portability, comprehensiveness and public administration -- the principles of the Canada Health Act.
In January 1992, my ministry announced a health reform agenda designed to ensure more efficient use of scarce resources and to shift the emphasis from treatment to health promotion and disease prevention. The reform agenda addresses the financial crisis in the health care system resulting from the spiralling costs of high technology, illness care and the fee-for-service system. It looks at the reduced transfer payments to the provinces for health and the oversupply of physicians.
Through the process of health care reform, we intend to better manage the health care system, invest more in community-based programs, redress long-standing inequities in the system and take a leadership role in preserving medicare.
Ontario's health reforms place new emphasis on health equity by focusing on groups that have historically faced barriers. Other areas emphasized include better management of the health care system, more effective use of health resources, participation and accountability within the system, review of expenditures, implementation of the redirection of long-term care and reform of mental health services.
New strategies are being developed for oncology, diabetic care, community health, tobacco use and human resources in health care, and new priorities are being identified in the areas of aboriginal health, women's health, children's health, AIDS and rehabilitation services.
Today I'd like to highlight our progress on three of those reforms: hospital restructuring, long-term care and mental health reform. Perhaps the best example that our strategy for change is working can be taken from the hospital sector and the reforms that we have introduced over the past two years. As members of the committee know, the reform plan for hospitals was introduced in November 1991 following a ministry review of hospital expenditures that involved all of the major stakeholders.
The main elements of the plan are to improve hospital management, to address duplication of services, to make hospital operations more efficient and to speed up the shift in emphasis from inpatient to outpatient care. The plan is now being implemented in hospitals across the province, and it's being implemented in an open, collaborative manner that is designed to allow the greatest possible level of local control.
During this process, we have created the joint policy and planning committee with the Ontario Hospital Association to improve the quality of ministry management decisions that affect hospitals as well as to give us a forum for working with the local district health councils and hospitals to resolve specific problems.
If we look across the broad spectrum of the hospital sector, there's considerable evidence that we've made major progress towards greater efficiency without compromising the general level of health of the population as a whole. I want to cite some relevant statistics here, statistics drawn from the period between 1987-88 and 1992-93.
Over that six-year period, the number of hospital days per 1,000 of population has decreased by 25%, while the average length of stay in hospital has declined by 17% to 7.2 days. Hospitals closed more than 5,000 acute care beds over that period, but the number of people treated grew by more than 8%, or about 1.2 million cases. This increase in services was made possible by a 23% increase in the number of day surgeries and an 8% increase in other outpatient services. In fact, day surgery, as a percentage of all surgery, increased over the period from 53% to 70%.
I don't have the figures as to what our hospital bill would be today if those 5,000 beds were still in the system, but I can assure you that it would be much higher. The key point I'm making here is that even if those additional beds had remained available, there's no evidence that our population's overall health would be any better.
In addition to the signs of improved efficiency we're seeing across the whole system, there are many local success stories that I could tell you about. Just as one example, I want to dwell a little bit on the efforts of the Windsor-Essex district health council, which recently completed a major local planning exercise that recommended the restructuring of local hospital services. The consultants' report that they've been evaluating and the community dialogue are talking about reducing the number of hospitals from four sites today to two or three sites when the plan comes into effect.
The DHC's work has been designed to eliminate program duplication, to improve coordination and to strengthen the linkages between the hospitals and the local community. While there's no doubt that a massive amount of work was needed to get to this stage, I think everyone involved agrees that the process will pay significant dividends down the road.
I've singled out the exemplary work done in the Windsor-Essex area, but the committee should be aware that major health system planning studies are also in development or under way in many other communities throughout the province, including Thunder Bay; Sudbury; Guelph; Belleville-Trenton-Picton, which have come together to do the study; Perth-Smiths Falls; Brockville; Durham region; Sault Ste Marie; Haliburton county; Halton; Peel and York region.
I think it's important to point out in this period of change in the hospital sector that the government's goal has been to minimize dislocation and job loss to the greatest extent possible.
In May 1992 we established the hospital training and adjustment panel. As a result, most hospitals now have local adjustment committees and laid-off workers are receiving adjustment services, and a job registry system has been established to match available positions with health care workers who have been laid off. Through the social contract process, there is agreement that the hospital training and adjustment panel's role should be expanded to benefit all workers in the health field.
Through reforms in funding, better utilization and better management of our institutions, as well as by establishing effective partnerships between labour, hospital administrators, the Ontario Hospital Association, other ministries, local communities and health care consumers, I believe that we've made great strides towards meaningful change in the way our hospitals are managed and operated. This progress will reduce cost in the short term, but it will also add to the long-term stability and sustainability of the system as a whole.
Another area of significant progress has been the redirection of Ontario's long-term care system, and I suspect we'll be talking about that in greater detail in the hours ahead. It involves a change in emphasis that involves developing more community-based alternatives to institutional care. Our long-term care reforms are predicated on the dignity and the needs of the individual and on the assumption that people should be able to live at home in their own communities for as long as possible.
After completing an exhaustive consultation process that involved all major stakeholders in long-term care delivery, including, I should point out, talking to long-term care consumers and their families, we recently introduced a package of reforms that will ensure the effective coordination of long-term care with other parts of the health care system. They will improve the way nursing homes and homes for the aged are managed and governed and will increase the involvement of communities, families and individual consumers in the planning, design and management of long-term care program delivery.
As with other aspects of our health care reform agenda, I think it's important to point out that the government is not looking to start from square one and to bring in changes simply for the sake of change. Rather, our goal is to enhance the services and programs that already exist and to make the system even better.
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I know that some members of the committee may have seen and I referred in the House to a recent article in the New York Times in which on the front page Canada's care for the chronically ill and the elderly was singled out for special praise. I think it's worth quoting parts of that article to the committee today. It said:
"Americans must use their own money for nursing homes or other long-term care until they deplete their assets; then they can qualify for Medicaid, the federal-state health program, a process that often leads to anguish and humiliation.
"No such restrictions exist in Canada, where there are some means tests for government aid but families are not required to sell off their assets. Those who are better off may be required to pay more but rich and poor live under the same roof, eat the same meals, go to the same social functions.
"So great is the fear in the United States of being forced into poverty by the costs of long-term care that more than 2.4 million Americans have bought costly insurance to cover the cost. In Canada, there is no such thing.
"No country has a perfect system, but Canada's, while continuing a process of creative tinkering, has caught the attention of specialists in the United States."
I was very proud of that story and it dwelt on institutions in Ontario and in the reforms that we've made under our long-term care system.
Our revised funding rules for patients in long-term care mean that seniors will not have to worry about being forced to sell the family home to pay for the care they need. Only a patient's income will be considered when fees are assessed. To be fair to everyone, all patients receiving standard care will pay the same and each person will be assured of a comfort allowance of $112 a month. These changes will mean dramatic savings for many elderly and chronically ill people throughout the province.
I would also point out that our flexible approach to change has already brought new benefits and higher levels of service to many communities. As one example, we can look at Eabametoong First Nation in Fort Hope, some 500 kilometres northwest of Thunder Bay. With assistance from my ministry and the Ministry of Community and Social Services, the first nation is building a new seniors' complex and multi-resource centre to provide care for elders from the five communities of Fort Hope, Marten Falls, Summer Beaver, Lansdowne House and Webequie.
None of these communities could support a seniors' home on its own and the closest facility is the EldCap unit in the hospital at Geraldton. The supportive housing provided by the new seniors' complex will complement the existing homemaker program and enable the first nation's elders to remain in their own community for as long as they like. The cost of the facility is modest, and I understand that the ministry also arranged for the city of Thunder Bay to give the first nation some surplus beds from the city's homes for the aged to furnish the new centre.
I mention this example as one of many instances in which we are managing the system effectively and actually improving the levels of service available to many communities. As Ontario's population ages in the future, our government's long-term care reforms will assume even greater strategic importance.
I'm also happy to report that the government is making significant headway in reforming another major area of our health care system, which is the treatment of people with mental illness.
As members may know, approximately 1.5 million Ontario residents, or about 15% of our population, have some symptom of mental illness. Our mental health reform package adopts many recommendations of the Graham report, Building Community Support for People, and is designed to enable communities to tailor mental health programs and services to meet individual needs.
Our strategy is to concentrate the bulk of services on the seriously mentally ill. We're also committed to making services available in a manner that is sensitive to gender, culture and race and to making the system more responsive to the needs of special groups such as forensic patients and victims of violence. In terms of specific outcomes we're looking to reduce suicide, to reduce disability from schizophrenia and other dementias and to create more employment for people suffering from chronic mental illnesses such as schizophrenia.
In the present system, patients are too often hospitalized by default, simply because they can't get appropriate treatment or services in the community. This unnecessary hospitalization is a needless waste of scarce resources. Even worse, it's a tragic waste of lives that could be much more full and productive.
Our goal is to enable people with mental health problems to receive the care and treatment they need, and preferably in their own communities, close to the nurture and support of their families and friends. At the same time, of course, we're committed to investing in modern, well-staffed and well-equipped institutions that can provide appropriate care for those mental health consumers who need it. As proof of that commitment, I would point to our announcement last month that we will spend $133 million to rebuild the Whitby Psychiatric Hospital.
In 1990, our government inherited a health care system that was virtually out of control, a system fed by annual spending increases in the order of 10% a year for the previous decade. Since 1990, a faltering economy and growing public debt have demanded decisive action to reduce costs and improve management in all areas of public spending, and particularly in health, which accounts for about one third of the entire provincial budget.
First, we sought to protect and preserve Ontario's system of universal medicare through better management of resources, controlling costs and reducing the runaway growth in spending that was such a prominent feature of the system for so long.
Second, we've sought to make sensible and strategic reforms by refocusing the system's priorities and placing a stronger emphasis on factors that lie outside our traditional delivery system but which in fact play a major role in determining the population's health.
As you know, the Ministry of Health's budget is over $17 billion this fiscal year, and while that's a tremendous amount of money, I would point out that it is a lot less than it would have been had our government not stepped in and made some hard decisions about putting the brakes on spending. In fact, I say with some pride that in the last fiscal year ministry spending grew not by 10%, as it had for the previous 10 years, but by just 1%, and this year ministry spending will increase only marginally, by about one fifth of 1%. This is a tremendous turnaround.
Through the social contract agreements, we intend to reach throughout the health care sector. We are committed to further reductions in costs totalling $470 million. These additional savings include $208 million for hospitals, $193 million for OHIP and the Ontario drug benefit program and $69 million in other areas of health spending.
Included in the ministry's $17-billion spending plan is a reallocation of some $82 million from the traditional health care system to the health promotion, community care side of the health care system. This will mean more money for family planning, for preventing sexually transmitted diseases and for smoking prevention programs. We'll be putting more ambulances on the road and putting more money into improving treatment for diabetics, especially among northern and aboriginal communities. We're opening a community health centre in a public housing project, and we're converting Burk's Falls Hospital into a community health centre. We're diverting almost $6 million to people with special needs, whether they are brain-injured, addicted or children with mental health problems. In the end, we will have added 4.8% to the health promotion, community side, while decreasing the traditional side of health by 4%.
While we've made excellent progress in slowing the growth of health care spending, let me assure you that the process has not been easy. In fact, for a system that experienced such rapid growth for over a decade, it was often difficult to absorb even the idea, let alone the reality, of major reductions in growth.
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I said that putting the brakes on spending meant some tough decisions for the government, but I also recognize that the government's decisions are requiring many others in the health care sector to make equally difficult decisions and choices in hospitals, laboratories, medical offices and other facilities throughout the province.
As members are aware, I recently released a detailed consultation paper on proposed reforms to the provincial drug benefit program. The paper was developed in response to significant concerns from a long list of stakeholders, including prescribers, pharmacists, drug manufacturers and consumers. The paper addresses many issues, including the fairness of drug programs, their cost and their quality assurance and management.
There is no question that reforms are needed in this area. The costs of the Ontario drug benefit program have grown by an average of more than 16% per year since the early 1980s, driven up by increases in the number of prescriptions, by higher drug prices and dispensing fees and by growth in the number of people who are eligible for benefits.
In the 1991-92 fiscal year, the ODB program paid some 42 million claims at an average cost of $24.80 per claim, of which $6.47 is the dispensing fee. Of the $1.2 billion spent on the program in that year, one quarter was for dispensing fees and the remaining three quarters was for drug products. But even with this huge government expenditure, more than two million people in Ontario today have no drug plan coverage at all.
It may interest the committee to know that the average physician in Canada writes between 4,000 and 5,000 prescriptions a year. For family physicians, the average is between 6,000 and 8,000 prescriptions annually. We also know that some 17,000 Ontario residents each year require treatment for prescription drug problems and that a significant percentage of all seniors admitted to hospital are there because of problems with their prescribed medication.
The fact is that although we've been spending more and more money on drug benefits, there's no evidence that the increases in spending have resulted in an improvement in overall levels of health. With an aging population, it is clear that we must manage drug benefit programs better, both to eliminate inappropriate prescriptions and to ensure that the system remains viable.
Our government's drug benefit reform package focuses on several key goals. These include improving prescriber education, controlling costs to keep the program sustainable, expanding the ODB program to cover more people, particularly the working poor, and forming new partnerships with consumers, unions, professionals and industry in the planning, delivery and evaluation of drug programs. If we are to achieve these goals, all the beneficiaries from the program, manufacturers, pharmacists and consumers, will be asked to share the costs.
I'm particularly pleased that our drug reform package will extend drug benefits to some two million Ontario residents who currently cannot afford or qualify for drug insurance. But I would also point out that through the drug reform secretariat we've made considerable progress in reviewing the management of Ontario's special drugs program, which is designed to cover people whose treatment depends on having access to certain high-cost drugs.
In 1986, the only drug covered by the special drugs program was cyclosporine, which is used to prevent rejection in organ transplants. Today, the program covers 11 different drugs and disease groups. Indeed, my office has received many letters of thanks from patients and parents of children with cystic fibrosis, a formerly fatal illness. The special drugs program allows cystic fibrosis patients to lead nearly normal lives. Indeed, one patient wrote that the program makes her more employable since it prevents her from becoming a drain on her workplace drug insurance plan.
The drug reform consultation paper was released last month, and we've asked for comments from stakeholders and the general public by the end of September. Once the ministry has had an opportunity to analyse the comments and incorporate them into the proposed changes, our intention is to get on with the process of reform.
In the meantime, we're moving ahead with a number of successful initiatives such as the province-wide computer network that will track prescriptions issued to seniors. This measure should help address the problems of overmedication and inappropriate prescriptions.
There are a number of areas that I've not mentioned which are high on our health care agenda. These include a range of aboriginal and northern health issues, they include initiatives designed to promote health for both women and children, they include measures to deal more effectively with HIV- and AIDS-related illness, to manage the demand and supply of health care professionals in Ontario and to promote more community-centred health care delivery throughout the province.
Ontario is Canada's largest province, and at more than $17 billion a year, our expenditures on health care alone are larger than the entire budgets of most other provinces. As I've said several times already this afternoon, we must not equate size with quality, because when it comes to delivering health care services, there's increasing evidence that this equation simply does not work. Despite its vast size and large population, Ontario is a network of communities both large and small. Our health care system must be flexible enough to serve people who live in all of those communities, people in Metro Toronto as well as people in Moosonee.
The fact is, our health care system provides a high level of service to most of our people despite the fact that their needs differ just as widely as do the communities and environments in which they live. As one example, I can tell you that the ministry operates 16 nursing stations in northern Ontario. Under this program, the basic health care needs of people living in these remote communities are met at the relatively modest cost of about $2 million a year. Northern nurses do everything from providing pre-natal care to sewing up cuts and applying bandages. They provide community-based care to the elderly, the sick and the frail, and they serve local residents in a timely manner, backed up by visiting doctors and air ambulance services for the seriously ill.
My point is that in order to ensure the effectiveness of the health care system, we must plan and deliver services based on the needs of the local people and the communities in which they live. Our success or failure will depend on the extent to which those needs are met.
I'm pleased that our government has had the courage and the conviction to curb the growth in health care spending, and I'm especially pleased and proud that, at the same time, we've made significant progress in reforming that system. We couldn't have achieved so much without the cooperation of our health care partners and other stakeholders, and I'm confident that we have acted together in the public interest by making the difficult decisions that were needed to save the system for future generations in this province.
While I think we can recognize that some of the seeds of change we are putting in place were sown by previous governments, it's clear that no previous provincial government has had the courage or commitment to tackle the need for real change in the health care system by controlling costs and introducing major reforms. I make this point not by way of apology for any shortcomings you might perceive in the ministry's activities; rather I make it to impress upon you how successful and productive our actions have been in such a short time, which has been one of the most difficult periods ever in the province's economic life.
I suspect I have provoked questions and comments, and I look forward to being with you. There are people here from the ministry with all the information that I think anybody could think of asking for. We certainly intend to attempt to provide whatever is needed so that the committee can have a fruitful and constructive discussion of our estimates. Thank you very much.
The Chair: Thank you very much, Minister. In accordance with our standing orders, I would like to proceed immediately to the official opposition and recognize Mrs Sullivan.
Mrs Sullivan: As we start the process this afternoon, I want to thank the Minister of Health for being here. You may recall that last year we had some difficulty, because the Minister of Health was not with us for the first portion of consideration of the estimates. She ultimately did come, but it caused some difficulty as we started our process.
Hon Mrs Grier: I wouldn't have missed it for the world.
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Mrs Sullivan: I'm sure you wouldn't have.
In opening my remarks, I want to speak specifically about the culture of the operations of the Ministry of Health under this government in particular. I find, particularly over recent months, that there is a clear consensus among most of the stakeholders who have to work with the Ministry of Health that many of the relationships with the ministry and indeed with the minister have deteriorated to the point where major barriers have been erected between the government and those who are expected to work with it.
In my view, the government has two significant stakeholder groups with respect to health care that it relates directly to and must relate directly to. Of course, the first group is the group of consumers, those people who are guaranteed the right to health care under the Canada Health Act. To a large extent, many of those consumers have come together in groups and organizations that represent a point of view, whether it's a patient support group, whether it's a family support group surrounding a disease or an issue, whether it's groups of seniors, of women, or other organizations that have become the spokesperson for consumers as they face issues and change in the health care system.
The other group of stakeholders is those who deliver the services, whether they're in facilities such as the hospitals or the nursing homes or those who are the health care practitioners and the professionals. Those are the second major stakeholder group.
In each instance, with the stakeholders who are the direct clients of the Ministry of Health, I find that there is an enormous commitment to the revitalization of the delivery of medicare for the end of this century and a commitment to a changed approach to health care delivery to meet the health needs of society that are different from those that existed when medicare was first introduced some 30 years ago.
I think there is little disagreement that indeed we have adequate money in the system, and the shifting of priorities, changed deliveries, changed health status, provide real opportunity for reform. In both the consumer organizations and in the practitioner-provider-deliverer stakeholder organizations, I find an enormous commitment to reform.
But I also find that a significant number of those stakeholders in either group believe now that the Ministry of Health is in a shambles, and that is a direct result of the government's own arbitrary and unilateral approach. I'm going to outline some of those issues, and I hope they will be addressed, if not to my satisfaction, at least to a partial satisfaction of some of the groups who are involved. The sense is that the process of reform is being negated by an adversarial, polarized approach which, as I indicated, has been taken, particularly recently, by the government.
If I can speak with respect to specific instances and examples of that kind of polarization, I have to of course refer initially to the breakdown of negotiations with the Ontario Medical Association. You know that the report of the umpire was one that was a particularly negative one, and I certainly understand why this government or any government would be sensitive about that report. It was a devastating report. It, in my view, was something that had to be corrected, and I believe the minister when she says it will be corrected, that her negotiators will be given a clear mandate and will have specific issues on the table that are clear and that place the government's position without bias and without distortion.
Let's look at some of the issues that led to that decision. We had the Minister of Health announcing on a day, on an occasion, that physician distribution goals would be changed and altered by a change in compensation plan for new physicians and that the new physicians who were entering the market, some 600, I believe, specialists who were leaving their residency and internship programs, would face a 75% fee differential if certain conditions were not met.
Subsequent to that, we know that the minister called on Dr John Evans, a man whose work I admire enormously, who gathered together a number of other people and presented a report which the Minister of Health then said publicly, in a scrum, that she supported and for which she hoped she would be able to obtain the support of her cabinet colleagues.
Clearly, she did not get that support, because I can tell you, to this day the OMA believes that both of those proposals are on the table. They are substantially different. They are an integral part but only one part of a physician resources strategy, but they are both floating out there and there has been no policy decision or announcement coming from the minister. We have asked for it in the House. My leader asked for it in a question; I asked for it in a question. The residents and interns association has made those same requests for information. It has not been forthcoming. That is the kind of clear difficulty that the minister, through her own statements and actions, has placed on the table that is problematic in dealing with the medical association, and there are many other issues.
The list of the OHIP services which was included in the expenditure control package as proposals for delisting included a proposal which had not been discussed in any way with the OMA, and that is for the delisting of psychoanalysis; I shouldn't say "delisting," but limitations placed on the access to psychoanalytical services. From the OMA's point of view, the issue was added without consultation, although many of those other items were included on that list after consultation, after a review of what was covered through medical insurance in other provinces.
In terms of psychoanalysis, I have a letter which was written to the Premier from Dr Norman Doidge, who is the head of the assessment clinic at the Clarke Institute of Psychiatry. He speaks of a backgrounder which announced the government policy to limit the number of psychotherapy sessions per patient, and says in this letter:
"It makes no more sense to legislate the number of psychotherapy sessions for all patients in the province than it does to legislate the dose of chemotherapy that every woman with breast cancer will receive or to mandate that every bridge in Ontario will be 250 feet long. This proposal seeks to fit all patients into the same mould and disparages and discards those who will not fit. When such a policy is based on inaccurate statements about psychotherapy, such statements must not go uncorrected."
Dr Doidge proceeds in this analysis to review material which was included in the backgrounder, a document of the Minister of Health, and one of his conclusions is that the artificial limitation on the number of psychotherapy sessions will mean that a number of patients go untreated.
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He says that two target groups are targeted by the decision. The first group is the psychoanalytic patients, 82% of whom have tried briefer treatments without symptom resolution. These patients amount to only 4% of OHIP psychotherapy billings and less than 0.1% of the Ministry of Health budget. The second targeted group, Dr Doidge tells us, are those with severe personality disorders or traumatic histories, many of whom require three-times-a-week treatment.
In his analysis, Dr Doidge is very precise about the kinds of issues which have to be faced and clearly considered in the determination of whether to include or to eliminate a service from medicare coverage.
But his plea is that in unilaterally introducing a policy statement, a cost containment statement that bears no relationship to the health outcome of those to be treated, the expertise of those who are involved in the field, in terms of the providers of this service, and the patients themselves also have a stake in determining and participating in the kinds of decisions that are being made.
The OMA was extraordinarily surprised, I know, as an organization to see that proposal included in the list of items to be changed under the OHIP schedule. Consumer groups of patients were extraordinarily surprised. I will tell you that they feel threatened, and I am told by a number of practitioners that many of them are indeed seeking additional treatment because a new threat has been placed on them and they fear that they will not be able to receive in the future the services they have in the past.
There are other areas with respect to negotiations with the OMA which are of concern. You will know -- I don't know if this Minister of Health knows, but certainly the previous minister did -- that I was sceptical when the JMC, joint management committee, came into existence. I am now convinced that it is an appropriate mechanism for discussion and believe that many of the initiatives that have come forward, particularly ICES, the Institute for Clinical Evaluative Sciences, which I'm very impressed with, are valid contributions to reform of the health care system.
As I move on to the next group, the pharmacists, I have to ask why a similar concept could not have been introduced in dealing with the issues associated with pharmaceutical management. The ministry once again rejected the mediator's report, which indicated that the ministry itself had not presented appropriate arguments before the mediator. The pharmacists' association has seen the drug network -- which may or may not ultimately be a very valuable, valid tool, but it was announced without consultation. It was announced without consultation on the technology and it was announced without information being provided to the pharmacists' association that the announcement was going to be made.
If all pharmacists are going to be participating in the network, surely the consultation on the technical and technological details associated with the setup of that network on issues surrounding the confidentiality of documentation etc should have been discussed with the pharmacists' association. They were not discussed with the pharmacists' association. As you may imagine, there was considerable disgruntlement with respect to that issue.
There were changes to the ODB plan in Bill 29, hidden in a bill that clearly was, if not an attempt to be duplicitous, one that, it seemed to me, did not provide any indication of a healthy respect for the pharmacists themselves and for their organization.
The issues that were on the table in connection with Bill 29 were ones that had not been discussed. The ministry has refused to set up a joint committee to discuss issues beyond the compensation issues, which are only one aspect of matters that should be on the table with pharmacists. If there is going to be, by example, an attempt to ensure that there is an increase and a particular commitment among the entire pharmacy profession to education with respect to the use of particular drugs, surely that kind of pharmaceutical management program should be on the table as a matter of discussion on a continuing committee basis with the OPA. It's not there.
I can move on to another sector, the hospital sector. We have seen this afternoon a news conference sponsored by the Ontario Hospital Association saying that the Ontario Hospital Association will not be signing the proposed health sector framework agreement. They are quoted as saying, "This is a bad deal for health care, bad for hospitals, bad for hospital workers and bad for all of those who use hospital services in the province."
You will know and I think you will agree that the hospitals in fact did sit at the table when many other groups and organizations such as the pharmacists did not. My view was that they wanted to participate in order to reach an agreement that was implementable. Their news conference today indicates that in fact it will be more beneficial for hospitals to have an agreement imposed under the fail-safe factor than it would have been for them to be a part of the entire social contract talks.
But there are other areas which were of concern to hospitals, and I will just mention one of them because we have a lot of lists of disgruntled people to go through.
When the papers were put on the table with respect to the social contract and the expenditure cuts, one of the things that caught many hospitals quite off guard was that the technical fee decrease under the expenditure control plan was not included in the hospital document. It was included in the physician document. It wasn't until many days subsequent to the issuance of these papers that hospitals received any information with respect to a requirement that was being placed on them because it was not in their paper, and they were not provided a copy of the other document until it was discovered, frankly, by someone who was looking at that sector and asked what implication it would have in local hospital service delivery.
Surprises such as that all the way through the relationship of the ministry with hospitals have been matters of concern for a long time and over many areas. Here's one in which the hospitals are both affected and another provider, in the hospital management of oxygen supply. On June 28, I believe -- let me just check this date -- there was an information item sent to providers with respect to a change in the delivery of home oxygen services.
The announcement and the directive came as a surprise in the end both to the private providers and to the hospitals because they didn't know it was coming. For the private provider, and I'm just going to move away from hospitals for a moment, the issues which were on the table at that point were the difference between the liquid oxygen and the other form of oxygen delivery and the proportion of the entire supply that should be and could be provided by the private providers.
Clearly, the government was looking for a 20% decrease in total costs and the liquid oxygen is a much more expensive vehicle in terms of delivery, but many people require the liquid oxygen and the physicians themselves must determine which patients require which form of oxygen. But two years ago the home respiratory services association provided data with respect to the service levels, with respect to targets, and negotiations were discontinued, or they did not continue on a regular ongoing basis.
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So when the announcement came out, it was a singular surprise, both to the association and the vendors, to see the proposals the ministry had put, which would have changed the compensation from $790 to $475 for liquid oxygen and to move the proposals for the concentrated oxygen to $400. I suppose that must be the private sector proposal.
What happened, though, would have meant that the people who required the liquid oxygen service, because of the need to change the equipment, because of the incentives which were needed to be put into place to use the concentrated oxygen -- because they were not in place, the targets were unreachable. Had there been ongoing discussion held with respect to the implementation of what was a legitimate target, a 20% cost saving in that area with no patients being adversely affected, I believe that the ministry, in working with the association, could have come up with a proposal that would have been workable, that could have been implementable on a time line that was achievable.
But that did not happen, and we have seen questions raised now as a result of that situation where there is concern that it's the intention of the ministry to move all of the oxygen services into hospitals, or at least, if not move them immediately, for a period of time there may well be a duplication of oxygen service provision between hospitals and those that are delivered in the community by the private sector, or there may be an attempt, a third strategy of the ministry, which would mean that the ministry did not want the commercial sector to be involved in home respiratory services at all.
The strategy, the policy direction, is very unclear and, once again, because of the unilateral, non-consultative way the announcement was made, because there were not, immediately before or even in a close period of time before the announcement, discussions with the providers as to the most efficacious way to make change, there is enormous disgruntlement with that particular provider group.
I see these same issues having come to the fore with the College of Physicians and Surgeons and many of the other colleges as Bill 100 was being developed, where the College of Physicians and Surgeons, as you know, had initiated significant work in commissioning the McPhedran report, had presented proposals to the ministry with respect to addressing an issue that was of some concern and for which there is large agreement, extensive agreement, as it's been called, for a zero tolerance attitude with respect to sexual abuse of patients by any practitioner.
What was announced came as a great surprise by the ministry to the colleges affected, because while the ministry had consulted, had welcomed the proposals that had been put forward by the CPSO and other colleges and had heard information from the victims' organizations, when the announcement was made for a one-tier complaint system for all levels of sexual abuse, I will tell you that there was shock in the CPSO. The recommendations that had been put forward had been well considered. There had not been discussion about the change in the approach that the ministry was going to propose, and when the announcement was made, the first response, and the only response, not only of the college of physicians but of many other colleges and many other individual practitioners, was that this would not work.
I know that the minister, if she hasn't announced this publicly -- no, you have announced this publicly -- is prepared to bring amendments forward when the bill proceeds, and that will be welcomed. But surely, some of the disgruntlement and some of the culture of antagonism could have been avoided had the discussion and consultation taken place before the jump was made. I am disappointed and I know that the colleges have been disappointed as well.
Once again, speaking with respect to some of the colleges which are affected, the professional bodies which are responsible for the standards and discipline within their own professions, every one of the health colleges that participated in discussions with respect to the consent-to-treatment and advocacy bills and all of those practitioners from the associations, and indeed people from the consumer groups, requested that there be ongoing and full consultation with respect to the development of the regulations under those acts. That has not occurred. No one has seen any work that's being done, or if any is being done, under those regulations.
Just as I'm mentioning regulations, I was speaking with representatives of the nurses' association today with respect to their signing of the social contract and the implications that they felt would be evidenced and experienced by their members. They had indicated that, along with many other stakeholders who were at the sectoral tables, they had requested participation in seeing the regulations under the social contract bill, Bill 48.
They want to review the wording, those who have agreed to sign now; and those who will be impacted by the decisions coming out of the social contract discussions, whether they're imposed or whether they have been agreed to, want to see the regulations before they are enacted. They want to be able to participate, to see if a word change or a direction change, which is clearly a possibility -- we have seen that in so many other regulatory developments -- that could affect any one of these groups negatively, could be found before the action is taken and not to have to create screams and hoots and hollers later.
I think there was an enormous unease among the consumer base as well about the stability and direction of our health care system. There was frustration about the lack of consultation and planning.
Consumer groups came to see me, and I'm sorry that I don't have time to move on to, by example, those who are affected by changes and reform of the mental health program. But many consumer groups are concerned that the issues that they have been putting on the table, as consumers in the mental health area, are not included in the mental health papers, are not seen to be a priority of the ministry as reforms to the mental health programs are made and they concur with me that they need to have more input, and they don't see a vehicle for more input.
Even with the consultation paper that's there, the individual who is looking for supportive housing, who is looking for the vocational support and so on, doesn't see an opportunity under the announcements that have been made so far for much immediate progress.
But I think as well that the individual hits that people feel have occurred, the target groups, the people who have been targeted for penalties, whether it's the psychiatric patients; the seniors organizations, which see themselves as having been targeted many times; nursing home residents, who see themselves being targeted through increases in their rents without a phase-in; home care recipients who feel unease about the availability of home care and don't see new services being placed on the ground as other services are being removed; the service deterioration which people see as they have to wait longer in hospitals for emergency or other treatment; longer waiting lines; inadequate information about what change is and how it's going to be brought about. Those are issues that, I think, are really frustrating all of the consumer groups that I speak to. You will, I'm certain, have received many of the same letters as I have, or similar letters.
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I think that the long-term care changes which have been presented are one example of where the information is so inadequate and where there is such confusion and fear that people indeed feel that they will not be served, that they do not have a place in health care. Understanding about the operations of that program is limited and there has not been the communications program and the direct involvement of consumers' organizations themselves in ensuring that not only will the changes work, but the people will know precisely how they will work.
The minister looks puzzled. Have a look at your own pink book on the implementation of the long-term care. Everything is very iffy and very long-term. The implementation plan is not clear in any way. The placement coordinating agencies are not clear. The role of the multiservice agencies and the shift from one to the other are not clear. People are very uncertain about where they're going and how they will be served.
Minister, my concerns are that there is an antagonism, a polarization that has occurred between you, your ministry and virtually every one of your stakeholder organizations and that, indeed, that is hindering rather than helping the course of reform of the health care system in Ontario.
The Chair: Thank you, Mrs Sullivan. I recognize Mr Wilson now. You have up to 30 minutes.
Mr Jim Wilson (Simcoe West): I appreciate the opportunity to make some introductory comments to the committee as we proceed to review the estimates of the Ministry of Health. I think the host of changes within Ontario's health care system and within the Ministry of Health over the past couple of years have presented this year's estimates committee with a considerable challenge.
I recall going through this process with your predecessor minister last year. I hope this year, in all honesty, it's a little more productive. Ms Lankin was very good at giving answers that contained very little content. Perhaps your style will be a bit different.
My efforts and those of my colleagues on numerous occasions and in various forums to secure critical information about the direction of the changes that the government has made to the health care system and the impact of these changes on the system have been met with resistance and hesitation. Judging by some of the ill-defined or haphazard policy that has been introduced by this government and by this minister, I can only conclude that those matters must be dealt with immediately in this open forum, and I intend to do that during this estimates process.
I think the challenge in front of this committee will be to secure answers to the questions posed by its members. My questions during this committee will tackle numerous policy areas within the Ministry of Health. What has become apparent to me, as the Ontario PC Health critic, and to my party is that there are some troublesome common themes in NDP health policy.
The first is the inappropriate imposition of ideology in the reform of health care services. The second is mismanagement, and I refer particularly to health cards. The third is the lack of vision to restructure the province's health sector in a comprehensive way.
Under the heading of long-term care: The reform of long-term care services in Ontario is one area in which I still have several concerns. One constant source of frustration for the opposition, through the consultation process on Bill 101, was the absence of any sort of detailed funding arrangement from the government.
In June 1991, the Minister of Community and Social Services announced that $647 million would be spent on long-term care services by the years 1996-97, but during public hearings on Bill 101 the parliamentary assistant to the Minister of Health was asked to provide a more detailed background of this total. This request yielded no new information.
With the release of the government's policy paper entitled Partnerships in Long-Term Care in April, a few more funding details were made available. Even with the few additional details on spending allocations, there are, however, numerous questions still left unanswered. The government has neglected to include any sort of breakdown on how the money will be spent on these projects. I intend during this committee to pose questions to you, Minister, that should address some of these outstanding matters.
Within the government's expenditure control plan, there was another vague reference to the funding of long-term care reform. This time, the government told Ontario's long-term care residents, clients, that, "Expenditures will be adjusted to reflect the need for the development and approval of community implementation plans." We have no indication from the minister what this actually means in terms of dollars or timing, and hopefully you'll be able to provide us with some assistance in this matter as well.
On June 25 you reannounced funding for one component of the NDP's long-term care reform. That was the expansion of the integrated homemaker program. While the minister claims the government is moving ahead with the reform agenda, she has yet again failed to back this promise by a date by which the funding will flow. Most recently, with the implementation of Bill 101's new user fees on long-term care facility accommodation, seniors feel, I think, that they've been dealt a blow by the NDP.
The government has failed to consider, among other things, the far-reaching repercussions of its policies on residents and their spouses trying to maintain the family home. To remedy the government's oversight in implementing its policy, I tabled a resolution, as you know, two weeks ago in the House that would allow for the phase-in of your new user fees to coincide with the flow of funds promised by your government over the next four years. When your government made the announcement back in October 1991 that it would commit $647 million to long-term care and community-based services, I think the government was somewhat misleading the public in terms of not making it clear that $150 million of that committed $647 million would come from the consumers themselves and would come --
The Chair: Mr Wilson, the word "misleading" is a rather strong word here. I'd suggest that the rules of the House do as well apply to committee. It's a rather strong word. I'm not asking you to withdraw; I'm just cautioning and suggesting it is a rather strong word.
Hon Mrs Grier: Mr Chair, the statement he made about the $150 million was part of the Liberal government's consultation paper, so if he wants to use it, I won't object.
Mr Jim Wilson: I just want to make a point to the committee members that I'm in a thoughtful and considerate mood today. That is probably the mildest term I can come up with. I sat through, along with many members here, the long-term care consultations and the committee hearings with respect to the bill, and it was like pulling teeth to get the government -- your government, Minister -- to admit that the $150 million was to come from consumers, that it would be in terms of new user fees.
I raise the point now, even though we've raised it several times over the past year or year and a half, because those new user fees have now kicked in as of the last month or month and a half, and seniors failed, I think, to heed some of the warnings that we gave -- and that's understandable, given that most people don't react until they're actually hit in the pocketbook. That's human nature. We're getting a lot of calls to our offices because seniors very much are explaining to us that they're surprised at the new rates in long-term care facilities -- nursing homes, charitable homes and municipal homes.
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I would say also with respect to long-term care, in regard to the proposed levels-of-care funding scheme, a whole realm of unanswered questions has been encountered. As of yet, the government has not released the specifics of the new classification system that will accompany this scheme. I hope we'll be able to get some additional details through this committee process.
The Ontario drug benefit program: We are still awaiting the release of details that will shed some light on the NDP's overhaul of the ODB. While the seven principles of reform and the six areas for consultation outlined in the government's paper suggest the general format of the government's hopes for a new drug plan, precise details are still missing. What is certain, according to you, Minister, is that Ontario's policy of providing free prescription drugs for all residents over the age of 65 will end some time in 1994.
It is uncertain where the government will draw the line between higher- and lower-income Ontarians. A proposal from your ministry's drug reform secretariat which was leaked in the spring of this year suggested that single persons earning $20,000 a year, regardless of age, should pay an annual premium as high as $300 to purchase drug coverage. Families with a total income of more than $40,000 would face the same expense, but as of yet, none of these figures have been confirmed.
I think seniors in this province need to know now how the government intends to proceed on its initiative to establish user fees on prescription drugs. I would also point out it's ironic that the NDP would be introducing user fees on seniors' prescription drugs. I don't recall your party ever campaigning on this platform. In fact, I recall for the past 20 years the policy of the NDP has been the exact opposite. At every opportunity, members of the NDP express their abhorrence concerning user fees. I think you owe an explanation to the people of Ontario with respect to your policy reversal.
Clearly, in the 1990 election, at the all-candidates meetings that I attended, the exact opposite impression was left with seniors at those meetings and through the literature distributed by your party. It was very clear to me in going to the doors, near the end of the election, that many people in my riding felt that the NDP indeed had a corner on compassion.
I recall you, along with David Peterson and the Liberal Party, labelling my leader Mr User Fee. If I sound a bit bitter over this point, it is because I am. While my party went through the last campaign being honest to people and talking about the need for reform, including reform not only in more general health care but specifically with respect to the ODB, your party I think mislabelled my leader and our candidates. I think if you don't have an explanation, at the very least you owe an apology to the people of Ontario.
In the area of mental health reform, the Ontario PC caucus has been supportive of the shift of certain health services from institutional settings to community-based ones. Certainly, this plan holds merit within the mental health sector. We've also demonstrated our support for this strategy throughout the discussions on the redirection of long-term care. However, we believe that the shift to community-based care must be more than just a change in location of services. The move must be supported by appropriate shifts in resource allocation. This is an argument we made repeatedly during the hearings on Bill 101 and have revisited in the context of mental health reform.
With respect to the resolution that I've tabled in the House, going back to long-term care, that resolution calls on your government to phase in the $150 million in new user fees over the same period that the government will be putting forward its share of the $647 million. I'd ask you to consider that resolution.
It seems to me it's unfair that under Bill 101 and under your long-term care changes -- I won't call them necessarily reforms -- you are asking seniors to pay a whopping 32% increase right now in user fees for accommodation in long-term care facilities, yet your government is in a fuzzy way promising to commit its money over the next four years. I think that's unfair and I hope you'll reconsider it, particularly if one uses the example of rent controls, where this year for accommodation in Ontario landlords are allowed to increase rents by only 4.9%, yet you're asking seniors to cough up an extra 32% immediately.
Back to mental health care: After numerous reports and a decade of efforts by the provincial psychiatric hospitals and community-based services, I think the NDP has failed to introduce a meaningful strategy to reform the province's mental health services and has produced no evidence of serious financial commitment to the restructuring. On June 16, 1993, you, Minister, released a government policy paper entitled Putting People First: The Reform of Mental Health Services in Ontario. The paper is intended to provide a policy framework for "the transformation of mental health services across Ontario."
But the PC Party, along with advocates for the mentally ill and the health care providers within the sector, is troubled by your government's plan, as the shift of services may very well come prior to the production of a comprehensive plan for establishing needed services and in the absence of the necessary reallocation of funding. It is my hope that this committee will be able to secure some of these necessary details.
What we don't want to see, obviously, is a repeat of what has happened in the past, and I admit that both the PC Party and the Liberal Party share some responsibility for throwing people out in the street without having appropriate community-based services in place. We don't want to see that repeated. Let's learn from the mistakes of the past.
Also, we don't want to see what's currently going on, in my opinion. You mentioned in your opening remarks that you've closed over 5,000 hospital beds in the last couple of years. You take great pride in statistics that show, in your own words, that the general health of the population hasn't been affected by this deinstitutionalization in the hospital sector. In fact, I think you went so far as to say that the general health of the population has probably been enhanced. I would challenge you to tell this committee exactly how you measure the general health of the population. It's a great phrase, but I think you owe it to us to explain what your instrument of measurement is for that.
I, as critic, have been approached and have brought to the Legislature on several occasions many cases of people who have been kicked out of the hospital or many cases where beds have not been available and community-based services are not in place. You know that Mrs Jane Leitch and the Senior Citizens' Consumer Alliance for Long-Term Care Reform earlier this year had a press conference indicating their frustration with respect to the fact that the money promised to the community-based sector in health care, the total dollars that we believe are to be committed, have not flowed quickly enough and that in fact there are gaps in services between those who can't access our hospital services and don't have access, also, to community-based services.
Private sector involvement in health care services: The Ontario PC caucus has been vocal, as you know, in its opposition to the NDP government's repeated attacks on private sector involvement in the delivery of health care services. We believe that public administration of the health care system should not necessarily translate into public ownership of all facilities. My caucus colleagues and I have been consistent proponents of the view that the private sector is a major contributor to the province's health care system, enhancing the quality and availability of service for all Ontarians.
We defend the critical role of the private sector in the delivery of health care services. We defended that role during the debate surrounding Bill 101, the Long-Term Care Statute Law Amendment Act, 1992. The NDP government, basing its decisions on ideology instead of pragmatism, has shown favour for the not-for-profit long-term care services, thereby ignoring the essential role the private sector plays in meeting the needs of consumers. This makes no sense to the PC Party, or to service providers, or to consumers.
The most recent example of the inappropriate imposition of ideology has been in relation to in-home health care services. What is more disturbing about this decision is the government's obvious disregard for the serious and disruptive spinoff effects this policy move will have on consumers.
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There are several practical problems with strict adherence to this not-for-profit preference, including the dislocation of workers, the creation of significant gaps in services and the limitation of consumer choice.
As Health critic, these issues greatly concern me, and I hope this committee process will allow us to discuss some of the implications of the reform.
Minister, your predecessor last year, in fact during this very process, promised me, and I have the Hansard, that she would meet with the private sector home care providers prior to any firm commitment on policy on behalf of the government. That did not happen. Ms Lankin never did meet with the private sector home care service providers; in fact, I would say she very specifically broke a promise she made in this very room last year. I hope we won't see a repeat of that from yourself during this year's estimate committee process.
I note in your opening remarks that there was no mention of the vital issue of health cards. As the committee is well aware, the mismanagement of Ontario's health card system has been an issue of tremendous concern to me and my caucus colleagues. I have been disappointed with the lack of action on the part of this government to address the serious problems within the health card system. Even after the Provincial Auditor and the public accounts committee have discussed at great length the specific areas of weakness within the system, we've seen no action -- I repeat: no action -- on the part of the government to stem the fraud in the system.
There's still much evidence of yet unresolved problems within the system, as I've demonstrated in the House on many occasions during question period, and during these proceedings I intend to ascertain exactly what the government feels it has done to remedy these problems, because to date I've not been satisfied with the responses from yourself or from your ministry. I want to know precisely what the government intends to do in the immediate future to stem the health card fraud.
I'll just say as a second-last point with respect to a discussion we had previously on Bill 100, which deals with sexual abuse by health care practitioners, that it's my understanding that both the College of Physicians and Surgeons and the coalition of colleges want to see the government's amendments, the actual wording of those amendments prior to second reading of the bill. I took the opportunity during the recess we had earlier this afternoon to consult with my House leader and my leader's office. I am told, just for your information, Minister, that the CPSO and the coalition of colleges want to see your actual amendments, the actual legal wording prior to second reading.
If I may suggest, with respect, you take that back to your House leader and see if they can't hash out among the House leaders whether we're having second reading within the next couple of weeks that Parliament is still sitting or whether it will be in the fall.
Of course, these are only a few of the areas I hope we'll have the opportunity to explore during the committee's allocated time on the estimates of the Ministry of Health. I hope as well that this committee will be able to learn from this minister how she intends to proceed with Bill 50, the Expenditure Control Plan Statute Amendment Act.
As you know, Minister, my party has voiced its opposition to the principle of this legislation, and we intend to fight it through the legislative process. All Ontarians are eager for further details on the government's intentions for the future of health care in this province, and as PC Health critic I will continue to urge the government to justify its staggering policy initiatives and supply us with rationale for its move to limit, reduce and restrict certain insured health care services.
Again, had my party formed the government after the last election, had we introduced a bill even remotely resembling Bill 50, I don't think it's an exaggeration to say that you and your colleagues in the NDP would be hanging from the chandeliers in the Legislature. You would not put up with this behind-closed-cabinet-doors unilateral delisting of health care services. That was never your party's stated public policy. In fact, with respect to Bill 50, I and my colleagues are completely shocked, as were the health care groups, your so-called stakeholders. For example, the OMA tells us that elements of Bill 50 came strictly out of left field and that many of the draconian measures in that bill were not discussed at the joint management committee, the JMC, and that it is unprecedented that your government would want and is in fact using its majority to acquire unprecedented powers with respect to who and how and how often health care services will be delivered in this province to the people of this province.
I think you owe it and your government owes it to the people of this province who pay for the services through their taxes to step back for a moment, to withdraw Bill 50 and to actually go to the public, which has been done in other provinces and certainly in some of the states in the US, and consult in a meaningful way with respect to asking the public the essential question, that being, what services would they like to see insured and what services would they perhaps agree to delist. I think there should be a priority rating of health care services and that priority rating should be established by the public and not by the cabinet behind closed doors, which is exactly what you're proceeding to do.
The PC Party has from the outset supported the principle of cost restraint and committed itself to supporting initiatives that achieve those goals in a fair and workable way. During the debate on Bill 48, the government's social contract legislation, we carefully considered the recommendations of organizations involved in the provision of health care services and we put forward the very thoughtful comments and recommendations made to us. We put those forward in the form of 29 amendments presented in the House during committee of the whole process with respect to Bill 48.
With the assistance of groups such as the Ontario Hospital Association and the Ontario Medical Association, we offered constructive suggestions to the government to improve Bill 48 to make it both fair and workable. To our disappointment, the government refused to even seriously consider any of our ideas and, along with the Liberal Party, rejected every one of our 29 amendments.
Minister, I refer you to the press release issued by the Ontario Hospital Association at 4 pm today during its press conference. The Ontario Hospital Association, on behalf of its 300 hospital representatives, met yesterday and unanimously agreed that it would be recommending that all of the hospital sector partners, the hospitals themselves, members of the OHA, not sign the proposed health sector framework agreement of July 15. The OHA press release reads, in part:
"This is a bad deal for health care, bad for hospitals, bad for hospital workers and bad for all those who use hospital services in this province.
"When we began the process of the social contract, we were told that it was about preserving quality services, saving jobs, reducing compensation costs to balance our budgets and assisting the government to reduce its deficit. The proposed government-union framework deal fails on all counts."
It goes on to say: "We entered this process knowing that there would be reductions in the scope and variety of hospital services available and that there would be job losses resulting from the government's rollbacks of $160 million under the expenditure control plan and $261 million from the social contract. That is why we tabled five successive negotiation positions outlining a wide variety of compensation cost-saving measures aimed at service reductions, minimizing job losses and treating all employees in the sector fairly.
"The proposed government-union framework agreement does not give us the desired flexibility to effect creative measures to avoid permanent job losses and reductions in services.
"In fact, the document moves in the wrong direction altogether. It allows, for example, for movement in the wage grid. For hospitals, that means additional payroll costs of $53 million a year." That point was made in the Legislature earlier this week by my colleague Chris Stockwell, the member for Etobicoke West.
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"The proposed agreement does contain provisions for a wage freeze, which is nothing more than cost avoidance. It produces absolutely no savings whatsoever.
"The fail-safe provisions of the social contract are more effective in lowering our sector's target. That is because movement on the wage grid is not allowed to undercut the wage freeze and because unpaid leaves of absence are made mandatory in the legislation."
Minister, I just read for your information that release of today from the Ontario Hospital Association. In essence, the OHA has rejected the government-union proposal and decided that it'd be better off under the fail-safe provisions of Bill 48. In your remarks to us this afternoon, you didn't acknowledge that the OHA was no longer going to be at the table. I think it's a severe blow to the social contract talks and I understand fully why the OHA can't endorse the government-union proposal.
I did want to ask you, with respect to that, you said in your opening remarks that you had hoped, through the social contract, to achieve savings of about $208 million. The OHA release makes it clear that the social contract savings were to amount to $261 million. I just wonder why the discrepancy between your figure and the OHA. Perhaps you could explain that.
In conclusion, the PC Party supports cost-restraint actions which will preserve the system, not dismantle it. We remain concerned about issues of quality, access and fairness and will continue to fight any measures that could result in long-term pain through inappropriate short-term savings. I thank you, Chair.
The Chair: Thank you, Mr Wilson. Minister, you have the balance of this afternoon's time, which is about 15 minutes and a little more you're entitled to, to complete your response. We're now in your hands.
Hon Mrs Grier: Perhaps we'll take the 15 minutes and respond fairly generally. With some of the issues that my colleagues have raised, such as long-term care for example, I think we'd probably be more productive to have the officials from the ministry who deal with that program here and deal with some of those comments and questions that people have in some detail on one of our other occasions. I've made a note of the various areas that have been touched upon and we'll make sure we have the appropriate people here to deal with those issues in detail, rather than me doing it in a more general way.
I do want to respond generally. Let me say that I certainly appreciate what I detect to be an acceptance by both of my critics of the fact that there need to be changes and there needs to be constraint. In fact the critic for the Liberal Party agreed with that and said that the stakeholders, both the consumers and the providers, agreed that the $17-billion-plus that we now spend on health care was sufficient and that there was a need for reform.
I think if we start at that common agreement, then it makes it at least easier to talk about the broad issues. But I would point out to the members that, okay, even with that common agreement, when you get down to the detail of how do you constrain the costs, what do you actually mean by reform, who is affected by the reform and how much is each particular party or stakeholder affected, then that agreement breaks down, because everybody has their own vision of what reform is or what constraint is. Unfortunately, in many cases it means that everyone else should be reformed, but not their particular group or their particular policy.
When I in my comments said that I thought our government had courageously taken this on, we have done that because we have acknowledged that there has been a lot of consultation, a lot of reports to this province ranging back to Fraser Mustard in the 1970s about the need for reform, but nobody has ever grasped the nettle and begun to do it.
When the member for Halton Centre talks about the disgruntled constituency that's there, let me say to her that I believe that no matter how much one tries to consult, how much one involves people in decisions, how much one includes people in the information network, when it comes to the end of the day, unless you have a total consensus, which is very difficult in this kind of a scheme, there's always going to be somebody who is disgruntled. From my experience in opposition, those people certainly found me early, found me frequently and, to some degree, were often the only side that I heard from, because everybody who was happy and pleased didn't necessarily come knocking down the door.
Having said that, I would not presume to imply that everybody has been pleased with the reforms that we have put in place. Let me refer briefly to some of the comments the member for Halton Centre made and to the various groups that she referred to as being particularly disgruntled. I want to set the record straight on a number of issues.
The member said, as an example of an adversarial approach to issues, that I had announced our proposal with respect to the discounting of fees for new entrants to the medical profession. Let me remind the member that this is an issue that is being debated in all provinces and between the OMA and the ministry for a number of rounds of negotiations.
In the opening of this year's negotiations, we placed at the negotiating table, before the Ontario Medical Association, our proposal with respect to fee discounting. It was the Ontario Medical Association that held a press conference the next day and released our proposals. I think it is important that the member know that.
I'm one of those who believes that negotiations are less likely to be successful if they're not done in public, and I regret the fact that that was how it started off with the OMA. I am delighted that we are now back at the table and discussing intensely with them the issues, some of which the member has raised. I suspect she may not be happy that I don't go into detail on some of the proposals because they are, as we meet, under negotiation, and I don't want to prejudice that in any way.
The other issue that the member for Halton Centre dwelt upon at some length was the question of psychotherapy, with the suggestion that again this had somehow dropped out of thin air and been a proposal by my ministry. I want to remind her that in fact this too, and the de-insuring of intensive psychoanalysis, has been an object of much discussion over the years.
In fact seven other provinces have de-insured psychoanalysis, and only British Columbia has set published limits, which are one hour per day. The other six monitor the psychotherapy billings by physicians and investigate those whose billing patterns are excessive, and more than 100 hours per year per patient is accepted as excessive by those provinces.
I would also say to her that a working group had been established under the joint management committee which exists between the OMA and the ministry and had been working for about a year on this issue. The final report of the JMC working group recommended specific changes to the OHIP payment policy for 9 of 20 items.
At the OMA's request, a final decision was not made regarding psychotherapy because its division of the psychiatrists within its membership was very much opposed to making any change, so that for us to again identify it as an item where savings could be made and an item for discussion with the OMA was, I think, an entirely logical conclusion of all of those discussions and not at all in the way in which the member has characterized it.
She also talked about the pharmacists not being involved in any discussion of the network with respect to linkages, and that again is far from the fact of how in fact the discussions by the Ontario drug benefit reform secretariat have been proceeding in its discussions on all aspects of reform. There may be a technical issue here that the OPA per se were not part of it, but certainly the representatives from that association were part of working groups and part of advisory committees, and this is again something that has been much discussed.
Let me just pick up on the point she makes about the need for a new relationship with some of the professions and ask her to consider that as we talk about reform, which means a broadening of the scope of the dialogue and an involvement of all of the professions in the health care system in the debate, I think we have to question, though I'm not ruling it out of hand, whether bilateral agreements with the professions are in fact the most appropriate way to discuss broader issues, because there are certainly, as she has in her enumeration of stakeholders, a broad range of people in the health care system who want to be at the table and to discuss these issues.
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As we wrestle with how best to consult -- and we've been accused of consulting to death, so it's interesting to hear my critics today perhaps suggesting we don't consult enough -- we have to look at it in the context of reform and perhaps change the way in which consultation has occurred in the past.
The group that has so often in the past been left out of the consultations is the consumers. The member for Halton Centre identified that as primary clients of my ministry, but consumers in every aspect are asking to be at the table and to be heard and are not happy if in fact arrangements are made between one particular profession and the ministry and their point of view is not heard. We have to take all of that into account.
I suspect we will talk at length at another time about some of the management issues with physicians and with the changes to Ontario drug benefits, so I won't go into that in detail now.
I did want to challenge another comment she made on the mental health reform, that there was no vehicle for more input. Again, we have finally, to the great relief of all the stakeholders, put out the ministry's policy framework and have established an advisory committee on mental health reform precisely to get more input as to how we can make that framework more specific.
She used the phrase "people who have been targeted for penalties." Without dwelling on that, given the time, I just want to take the greatest exception to the use of that kind of a phrase to a government that has been struggling to make sure, as we constrain costs and deal with very difficult issues, that any pain or penalty or cutback is shared as fairly as possible and as widely as possible by all participants in the system.
The member for Simcoe West talked about the imposition of ideology. I invite him to review the literature and go back to the reports. In my remarks I paid tribute briefly to the fact that in much of what we were doing, the seeds had been sown by previous governments, and even by the government of the party he represents. I made reference to the Mustard report and the other work that has been done more lately by the Premier's health council. So to say ideology drives the decisions of this government -- if he examines the record, he will find that in fact there is a broad consensus about the reforms we've initiated.
I agree with him. When it comes to the role of the private sector, we believe that health care services are more appropriately delivered by the public sector and that, as we look at scarce dollars, it is in fact appropriate to make sure they are used for services and for wages and not for profit.
I don't know whether you want, Mr Chair, to look in detail at the health card issue. I know the public accounts committee has been doing that exhaustively, but if the committee wishes me to bring people here who can address that, I can.
With respect to Bill 100, again I can detail the record of consultation and involvement with both the survivors of sexual abuse of patients and the professions on that bill. Let me say to both my colleagues who suggested a delay in second reading of that legislation, second reading is to discuss the principle and I don't believe either of my colleagues disagree with the principle in Bill 100, which is that the sexual abuse of patients by professions cannot and must not be tolerated.
The question of amendments to the legislation and the wording of the legislation will be debated exhaustively when we are in committee and in hearings and before it comes back to the House for third reading. My reason for not having shared with my colleagues the precise wording, though they know precisely which sections of the bill we are prepared to amend, is because I think we need to have the hearings and the consultation before we write the amendments. I suspect that had I tabled the amendments before the public hearings and before the hearing from the stakeholders, they might well be accusing me of having pre-empted the discussion and not allowed for consultations.
I ask them to consider the message they are sending by saying that their House leaders will not agree to second reading debate on that legislation, because second reading is debate in principle and, frankly, I want to get on with it.
Mrs Sullivan: On a point of order, Mr Chair: I ask the minister to correct the record. Certainly, from my point of view, I put nothing on the table today with respect to House leaders or my House leader giving --
The Chair: I don't think the comments were attributed to you. They were done in a generic way and they were not attributed to you personally.
Mrs Sullivan: Motives are being impugned when the leader is quoted as having indicated --
The Chair: It's not a point of order, honestly.
Mrs Sullivan: Could I ask the minister to correct the record?
The Chair: No, you cannot. The minister has the floor.
Hon Mrs Grier: Let me then say that as I understand it, those members suggested that the amendments to that bill should be tabled quickly. You've heard my reasons for not wishing to do that, and as I say, my urgent desire to debate second reading so that we can establish clearly, for survivors who think we have moved too slowly and for professions that want to know the opinion of the Legislature, that nobody -- and I believe I'm clear in saying nobody -- in this Legislature is going to oppose the principle of not tolerating sexual abuse against patients. Let me conclude --
Mr Jim Wilson: Point of order, Mr Chair.
The Chair: What is your point of order?
Mr Jim Wilson: If I just may correct my record then, because I understand that the minister --
The Chair: Your opportunity to correct the record is not a point of order.
Mr Jim Wilson: I would then ask the minister's indulgence to clarify the point that she's making. It'll take 30 seconds.
Hon Mrs Grier: Happy to --
The Chair: It's not a point of order. I recognize the minister.
Mr Jim Wilson: Mr Chair, the minister just said that she would be would be happy to allow --
The Chair: She needs to have the floor in order to respond, Mr Wilson.
Hon Mrs Grier: I would be happy to cede part of my remaining two minutes to the member for Simcoe West.
Mr Jim Wilson: We can extend your time, Minister, if you want. The simple point I was making is that --
The Chair: I'm not prepared to sustain a second challenge today.
Mr Jim Wilson: -- during the break, I consulted my House leader, trying to be helpful and I was simply passing on to you what came most recently from the CPSO and the coalition of colleges, and the most recent request of my party, from them to you through me, is that they see your amendments' legal wording before second reading. I was passing that on to you for your consideration. It's obvious that you're rejecting that.
Hon Mrs Grier: No, I'm not rejecting it. I'm expressing --
Mr Jim Wilson: Well --
The Chair: Mr Wilson, you've stated the case. Please allow the minister.
Interjection.
The Chair: Mr Wilson, you are out of order.
Interjection.
The Chair: No. Mr Wilson, you are out of order. You're not being recorded.
Mrs Sullivan: Could I have the same opportunity?
The Chair: I have recognized the minister -
Mr Jim Wilson: I recall --
The Chair: Mr Wilson and members of the committee, we are here to complete the estimates of the Ministry of Health. Each member and each caucus will be given a full opportunity to respond. We have 10 hours allocated to these estimates. In the one minute that is left remaining before the clock requires us to adjourn, I wish to advise on some procedural matters and then we will reconvene.
There have been several requests for additional information. For the record, I suspect the staff who are here will have no difficulty and where possible will bring that material forward at the commencement of our next meeting on the 27th, and where possible will present that at the commencement of our estimates hearings. That would be helpful. I sense there is agreement from the minister and the deputy.
The Chair, with the responsibility of ensuring fairness of the time, recognizes the minister still has six minutes owed to her. She may choose to use those. But unless you have a final comment, Minister, I would seek a motion for adjournment.
Hon Mrs Grier: Happy to adjourn.
Mrs Sullivan: I would like --
The Chair: I will hear a point of order only, Mrs Sullivan. I cannot acknowledge interjections.
Mrs Sullivan: Mr Chairman, the minister indicated that I had --
The Chair: You're out of order. Mrs Sullivan, I indicated to you, either I hear a point of order or that is an interjection. I cannot hear an interjection.
Mrs Sullivan: Point of order: Bill 100, which I spoke with the minister about at the recess, as did Mr Wilson, is at the request of the government House leader -- and I have the list, which is now being discussed and has been discussed among the House leaders, for consideration in the House.
On this list, it says the deferral of Bill 100 --
The Chair: Mrs Sullivan, you do not have a point of order, and I might show you the standing orders which indicate, quite frankly, that there are certain --
Mrs Sullivan: Mr Chairman, the minister has had --
The Chair: Mrs Sullivan, you're out of order. This meeting stands adjourned to reconvene on Tuesday, July 27, following routine proceedings, to continue the 1993-94 estimates, in room 151.
The committee adjourned at 1801.