Assemblée législative de l'Ontario

MINISTRY OF HEALTH

CONTENTS

Tuesday 27 July 1993

Ministry of Health

Hon Ruth Grier, Minister

Margaret Mottershead, assistant deputy minister

Gilbert Sharpe, director, legal services

Michael Ennis, assistant deputy minister, population health and community services

Patrick Laverty, director, long-term care policy

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 Jamison

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 / Greffier: Decker, Todd

The committee met at 1534 in room 151.

The Chair (Mr Cameron Jackson): I'd like to call to order the standing committee on estimates. I have one item to report. I received about an hour ago correspondence from the government House leader which I'll read to the committee. It's addressed to the Chair of the standing committee on estimates.

"Mr Jackson:

"As per your request of June 28, 1993, on behalf of the standing committee on estimates, the House leaders have agreed that this committee will not be authorized to sit during the intersessional."

So that it is clear to all committee members, we will complete our estimates while the House is sitting and then when the intersessional is over -- and I believe the date that's been targeted is some time late in September -- we can reconvene to continue the estimates. If we do not complete a given estimate, it'll be carried over and be completed when the House has authorized us to meet. Are there any questions at all on that? Okay.

MINISTRY OF HEALTH

The Chair: I'd like to reconvene the estimates of the Ministry of Health, to again welcome the minister and the deputy minister, Margaret Mottershead, and to inform you that we have used about two and a half hours of our 10 hours and that when last in our rotation the minister had the floor with approximately five or so minutes to finish her summary remarks. I believe, Minister, you have brought with you some information that came from questions raised by the opposition critics from our last meeting.

Hon Ruth Grier (Minister of Health): I just wanted to take a couple of minutes to touch on some of the questions that had been raised, and there are a number of officials here from the ministry, so when the committee decides what areas it wants to address in more general questions, we can get the appropriate people to answer.

There were a couple of points raised when I was here before that I wanted to address, and one particularly, because it was important to set the record straight.

The comment was made or a question was raised about the savings that the ministry hoped to obtain from the hospital sector as a result of the social contract negotiations. The figure used was $208 million, compared to the figure of $260 million, which is the one being used by the Ontario Hospital Association.

I think it's important that we be very clear that, in a sense, both numbers are correct. The ministry's figure, the $208 million, represents the total savings anticipated from the hospital sector, assuming that the social contract negotiations are successful and that an agreement is reached. As you know, the government provided an inducement for reaching such agreements that amounts to a 20% reduction in the savings required from total compensation where the negotiations have not been concluded. The $260 million represents the total savings required if no social contract agreement is reached.

I think it's important that those figures be clear, because we have until August 1 to reach an agreement. As I think members know, the Ontario Hospital Association has indicated it is not prepared to sign the agreement. The effect of that refusal may well be that we're looking for savings of $260 million as opposed to the $208 million that would be required should a sectoral agreement be reached.

The other question I wanted to address was one where one of the critics spent some time talking about user fees for long-term care. I want to point out first of all that the government's plan for long-term care reform calls for standardizing the accommodation fees paid by residents in nursing homes and homes for the aged right across the province, and that it's important to be very clear about the fact that accommodation fees are not user fees. They represent standard charges for accommodation, costs that residents would have to bear if they were living in the community and therefore required to pay for their own food and shelter.

If they are in a long-term care facility or a nursing home, all of the nursing care and quality-of-life programs, such as physiotherapy, are paid for by the ministry. So when the phrase "user fees" is used in conjunction with long-term care, it is, I would submit, inaccurate.

As the committee will recall, our long-term care program requires the standardization of the accommodation fee for all long-term care residents, and that will be standardized at $38 per day. Ability to pay will not be a barrier to care, since the subsidy will be provided to those residents who don't have sufficient income to pay for their accommodation. The standard accommodation fee will be $38. If your income is such that you cannot afford to pay that, then there will be a subsidy available.

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The reason for this was the very wide variation in accommodation fees across the province, ranging everywhere from $26 to $90 a day for essentially the same services. Common sense, to say nothing of the extensive consultations that were carried out prior to introducing our long-term care proposals, told us that this kind of discrepancy was inequitable, and so our proposed changes to the system are designed to address that inequity very directly.

There were also some comments made about mental health reform initiatives. I think all members have a copy of the grey document, the backgrounder, that was made available at the time of the budget. If not, we probably have other copies.

In that, there's a very clear graph that shows the shift over the last 10 years in expenditures on mental health reform from public and psychiatric hospitals to more community-based services. Not only does it demonstrate the shift, but it demonstrates the enormous increase in spending by the Ministry of Health over that decade.

In 1983-94, not just mental health but all of the community-based services -- long-term care, community and public health programs -- received a combined total of just 10% of health care spending. By contrast, public and psychiatric hospitals were receiving 50% of all expenditures.

If we compare those numbers with the situation this year under our government, we find that long-term care, community and public health programs will receive 15% of all spending and that public and psychiatric hospitals will receive 44%.

These numbers clearly establish a significant shift in emphasis in health care and, I believe, a more appropriate balance in spending of our health care resources than at any other time in the past. There's a great deal of work yet to be done, but we believe we've set a firm direction for policy for which both consumer survivors and mental health care providers have praised our leadership in going in this direction.

The third area I wanted to touch on was the drug reform initiatives, and I suspect in questions we'll get into this in more detail. I wanted to remind the members of the committee that the need for reform in this area has been very well documented from even before the report of the Lowy commission, which I think reported in 1989-90. There had been extensive documentation that overmedication was a major concern for seniors in the province, and so the principles that we've established in our reform initiatives and our current consultations will provide the basis for a major restructuring of that entire program.

As I announced some weeks ago, we've been working with pharmacists throughout the province to implement a new computer network for Ontario drug benefit subscribers, and that network will enable pharmacists to access prescription information about clients of the program. We hope that will really help us to reduce problems associated with overmedication and inappropriate prescriptions.

I also want to point out that our proposal for cost-sharing under the Ontario drug benefit plan is designed not only to keep the program manageable but also, and most importantly, to enable us to increase the number of people who receive benefits under that program so that we can extend essential drug coverage to the two million people across the province who currently have no benefit at all.

Finally, in response to the suggestion that was made last time we met that our government is introducing changes to health care without adequate consultation, let me remind members again, as I said the other day, that we have too often been accused of consulting overly as opposed to moving and getting on with some of these reforms, but each of our major reform initiatives, including long-term care, mental health, hospital restructuring, access to midwifery and abortion services, changes to the Regulated Health Professions Act, proposals for drug benefit reform, each and every one of those reforms, which are now well under way and on which action has been taken by our government, was preceded by extensive consultation and includes extensive consultations and discussions with both consumers and providers. As far as I'm concerned, there's no other way in which we can make the changes that we are suggesting in order to improve the quality of our health care system.

Let me say yet again that we have strengthened the role of district health councils across the province. As I visit different communities, I continue to be impressed by the thoughtful and dedicated work of hundreds of volunteers and staff who are restructuring our health care system through extensive local consultation. Again, that's something that has been called for for many years: Instead of merely a centralized policy-making process, it allows the different regions of the province to have input into what kind of program delivery there is in their regions that reflects the diversity of both the populations and the communities around the province.

But let me say that having consulted widely, having reached a level of consensus about the need for change, there comes a time when you must act. Over the past five years, our health care system has been examined and analysed by numerous expert committees, including Spasoff, Evans, Podborski, Barer-Stoddart and the Premier's Council on Health Strategy. It was the work of all of those experts and the consultations they undertook that helped to develop a consensus on the need for changes in health care management and delivery.

Our government has had the courage and the commitment to tackle some of the major challenges involved in restructuring the system, and to a great extent, we're succeeding in our goal of ensuring that delivery of health care in Ontario is universal, accessible, portable, comprehensive and affordable, those principles from the Canada Health Act that I quoted in my opening remarks to this committee.

According to the Ontario Health Survey which was conducted as recently as this past January, some 94% of the population had no problem seeking the health care they needed. I know my critics will promptly quote a poll that was released recently by I think the OMA or the Ontario Hospital Association yesterday or today that will dispute that figure, but I would venture to say that this most recent poll perhaps says more about the effectiveness of a $3-million advertising campaign which says medicare isn't working than it does truly reflect the views of the people of this province about a health care system which they've helped to create and of which they are very proud.

I firmly believe that the vast majority of citizens, the 94% who responded to a poll in January, have no problem seeking the health care they need. Our goal, of course, is to raise that figure to 100% and to continue making the shift to preventive approaches to care and treatment that will keep both our population and its health care system healthy for many years to come. That is the underlying philosophy and approach behind the estimates that this committee is addressing today.

I welcome questions. I have a number of people here from the ministry, and more can be reached speedily if there are issues that committee members wish to address and questions that I haven't answered.

Let me conclude by perhaps suggesting that if it's the wish of the committee to make some determination as to which particular issues it wants to address today or tomorrow, earlier or later, that might be a more efficient use of ministry staff and time. I'd be more than happy to work in that fashion if that's how you normally deal with estimates. Thank you.

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The Chair: Thank you very much, Minister. We are now, at this point, responsible for ordering up how we wish to proceed with estimates. The minister has introduced the notion that we may wish to go by votes and that staff from the various ministry departments would be present on the days that those votes are being discussed. I'm in the hands of the committee, whether you wish to go in rotation, whether you wish to go by votes or whether you wish to proceed generally with the estimates. At this point, I should advise you that I have received no special requests for the specific attendance of a specific department head, ADM or otherwise.

Mr Jim Wiseman (Durham West): Are you asking us if we want to vote on each section as we go through it, or are you just asking us if we wanted to have specific staff here to discuss specific policies?

The Chair: The standing orders suggest that if the committee determines that we shall deal with a vote item, then we will only deal with those vote items. In vote 1601, for example, which deals with ministry head office or ministry administration costs, then you would be limited to questions in that area until we were done with that; you would then stack that vote, but you would not be able to come back to administration vote 1601 without unanimous consent. That's how our standing orders address that.

As a new member of the committee, I could only suggest to you that we have operated in a more flexible fashion, but there is a world of difference between the two votes in the Ministry of Skills Development and the four votes in the Ministry of Health which cover $17 billion in expenditures.

Mrs Barbara Sullivan (Halton Centre): I felt the process that was used last year when we were dealing with Health estimates was a valuable one, in that we proceeded in rotation with a 20-minute time span for a representative of each of the parties to address questions, and when necessary or advisable, we were able to return to those areas subsequently in discussion, frequently with additional information provided by the ministry so that where an answer hadn't been complete at the time, it was allowed to be completed.

That is my preference. I feel it was most valuable in that as members of the committee we were able to choose our priority areas from a broad and expansive hierarchy of issues that would be faced in health care.

Mr Jim Wilson (Simcoe West): I agree with Mrs Sullivan. I think last year was very productive in estimates. We simply went in rotation, with 20 minutes or a half-hour allocated to each of the parties. It's almost necessary to do that, given that a lot of questions that come from the parties are general in nature and may deal with ideological factors and don't actually point to any particular vote item. That's what happened, actually, last year: We started to do it by vote by vote, and we ended up deferring to simply a rotational basis.

The Chair: Then we will proceed in that fashion. To the extent that there are requests for staff to be here, then the ministry will attempt to accommodate that, but if the persons cannot be, then simply a request that those who could be here would be here. But we are doing 10 hours, so we will have four or five days of estimates; it was simply an attempt to ensure that the appropriate staff were available when members of the committee wished to pursue direct questions, so we'll exercise some flexibility in that regard.

Mr Jim Wilson: Just with respect to staff present, I know it's difficult for the minister to anticipate every question that might come from the critics or from her own party. I'd certainly say there's nothing wrong or shameful in the fact if the minister simply tells us she doesn't know a particular answer and a staff member isn't available, as long as we get the assurance that we'll have the information we do request at some point in the near future.

The Chair: Are there any items that the minister has to hand out, any information that was prepared?

Hon Mrs Grier: No.

The Chair: Not at this time. Fine.

We will proceed in 20-minute rotations, and we will commence with Mrs Sullivan. You have the floor.

Mrs Sullivan: Having said that it wasn't necessary to proceed in order, vote by vote, I clearly want to start with vote 1601 relating to the ministry administration, and particularly to those expenses that are listed under main office operating. I'm going to be specifically asking for additional written material with respect to the minister's own staff, the staff of the parliamentary assistants and of the junior minister for Health, including the numbers of employees, salary ranges for those employees and the duties of those employees.

I would also like to see covered, if I could, in that written response, information about what in fact the junior minister of Health does and what specific projects she's undertaking.

In terms of an oral response today, though, I would like to know from the minister why her staffing envelope went up by a quarter of a million dollars, according to the estimates, and to what purposes that money is being put.

Hon Mrs Grier: The increase reflects the addition of the minister without portfolio to the Minister of Health, though that of course is not all attributed to that. General increases in that staffing -- this was for change from 1992-93. I don't know whether a part of that was the change in responsibilities for the Ministry of Health and the transfer of long-term care from the Ministry of Community and Social Services to the Ministry of Health. We'll get you the breakdown of that.

Mrs Sullivan: It appears, Minister, that the transfer costs are included under vote 4 and are not included in this area. The minister's staffing envelope is specifically indicated as an expenditure change with an increase of $253,500. That appears to be, from my point of view and I believe from the point of view of a reasonable person who's looking at expenditures of the ministry, an extraordinary change. It's over a quarter of a million dollars, and indeed there has been no change in the responsibilities of the Minister of Health. You still have the same powers you had last year, the same workload, the same responsibilities to the people of Ontario, but a quarter-of-a-million-dollar increase in the staffing envelope. I think the people want an explanation of that.

Hon Mrs Grier: Let me again say that there has been a shift in responsibilities, which is the movement of the long-term care to be the sole responsibility of the Ministry of Health. The figures that you referred to on vote 4, I suspect, are the switch in funding and ministry staff into the Ministry of Health. There was a concomitant adjustment in the ministers' staffing envelope as a result of that, and the envelope for all the ministries has been established to recognize the levels of the various responsibilities and is not the same from one ministry to another.

Mrs Sullivan: I think that if you were on this side of the fence, you would say that a quarter-of-a-million-dollar increase in staff of the minister is an extraordinary increase. Ordinarily, as I understand it, when a person is seconded from the ministry, that person's remuneration package is still included as an expense of the ministry.

The redirection of the long-term care from Comsoc to the aegis of the Ministry of Health is accounted for in the accounting provisions of the ministry in different ways. It's shown as a reallocation within the ministry and a reallocation or transfer from other ministries. This particular new expenditure of $253,500 requires an extensive accounting. I'm asking for that, and I'm asking for that before the estimates are complete.

Hon Mrs Grier: I understand your question, Mrs Sullivan. I haven't got the figures at my fingertips, but I think what you will find if you look across all ministries is that the total staffing for all ministers' envelopes has remained static. What has happened has been some shifting by the Premier's office within that envelope to reflect those ministries, for example, the Ministry of Education and Training, where there was an increase in responsibilities. As part of that, the Ministry of Health is one of the larger ministries, even though in the particular reorganization that occurred earlier this year, the only specific change that had occurred was the addition of long-term care. Within the overall government expenditures for ministers' staffing there has not been a major increase. The redivision of that funding is reflected in an increase in a number of ministers' budgets, of which this is one.

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Mrs Sullivan: How many people have you added to your staff to deal with long-term care issues?

Hon Mrs Grier: The staff, as it was when I became minister in February, has changed, and the numbers I don't have at my fingertips. I will get that in response to the question that you've asked to have in writing.

Mrs Sullivan: The other issue I suggest to you is that the long-term care responsibilities had been transferred to Health prior to your becoming minister, and as a consequence I don't see that as having an impact to the level of the quarter of a million dollars that has been indicated. I will thank you for providing that information. I think it's important public documentation.

I'm going to move on to another area because time is short is this rotation. Under 1601-1, "analysis, research and planning," the operating provisions which are included on page 43, while I know that you have given evidence that you're reluctant to talk about issues that are on the table with respect to negotiations with the joint management committee and the OMA, I would like to have an assurance that the funding for research projects which are being undertaken by ICES, the Institute for Clinical Evaluative Sciences, are not jeopardized and that all of the research projects that have been initiated will continue and that new ones which were expected to be initiated over the next period of time, whether they're single-year or multi-year, will not be jeopardized in any way.

Hon Mrs Grier: I'm happy to give the member the assurance that none of the work of ICES has been jeopardized, as she puts it. Let me say that none of the work of ICES has been affected by the constraints within our ministry and that its budget is intact, which I hope the member will recognize is a recognition by the ministry of the value we attribute to ICES and the enormous potential we see through the work of that institute for providing us, for the very first time in the history of the health system in this province, with some independent evaluation of a number of procedures and practices that have been going on for a very long time and of which there has never been any objective evaluation in the past, which will therefore assist us as we look to see what is in fact medically necessary and how we constrain the cost of the health care system as well as managing it more effectively.

Mrs Sullivan: As you know, I'm a strong proponent of the work that's being done by ICES and believe that Dr Naylor and the people who work with him have a substantial contribution to make to the future planning of the health care system here, and I'm sure that not only ICES but the joint management committee of the OMA will be delighted to hear that response.

Also in the research area, we know that Dr John Dirks, who was the former head of the faculty of medicine at the University of Toronto, has completed a study for you, which I understand you have now received, with respect to the initiation of an Ontario health research council. Dr Dirks interviewed Health critics and other members of the Legislature, as well as people who are involved in research activities in the health care field, both from the public and private sector, and his report is now in.

In the course of that interview, my particular feeling was that the initiation of a health research council would be a valuable option, that it could lever funding to coordinate research projects that would be of value in the province. I felt, and indicated to him, that not only should the research council be an opportunity for pure research but also one for market development, and that the development side of research projects should have a clear consideration and be a functional part of the operation of any council.

To date, although you've had the report for some time, we have had no action: We have not seen a response in terms of what your policy is going to be with respect to setting up a health research council or the kinds of consultation you would undertake now that the report is in and you've seen the thread and the direction of his recommendations -- which, by the way, are still limited to being information and advice to the minister and are not publicly available. I don't think Mr Wilson has seen that report, and I have not seen it. I'm sure, however, that it is a fairly complete report and may have indicated other areas of exploration that might be needed. What is the status of that report? When will action be taken? How much have you allocated in your research budget for the initiation of a research council?

Hon Mrs Grier: Let me agree completely with the member that the work Dr Dirks did and the whole question of a health research council for the province of Ontario is extremely valuable and has been very helpful. I regret that we haven't been able to move more quickly on the implementation of that, but let me assure the member that that doesn't reflect any lack of interest in moving forward in this respect. In fact, I've had a number of conversations and briefings and meetings about what form such a council should take in Ontario and how such a council can reflect the shift that is occurring in Ontario and our health care system and our desire to make it a better system and to restructure it so that it can take us into the next century. So the options and the recommendations that are in that report are still under review.

I would agree with her that there are in fact links to health and economic development. I think members are probably aware that within the Ministry of Health, an economic development division has been established so that we can make effective links between the exceptional research and innovation that is going on not only in our hospitals but in our academic health science centres and around the province, to make sure we take the greatest possible advantage of that work and transfer the technology to uses that can benefit the economy. As we look to not only a restructuring of health care but a restructuring of the economy of this province, we realize that we need to create jobs in sectors that perhaps we have not looked to as being opportunities so much in the past.

Certainly, with the degree of public money, a third of our provincial budget, that is spent on health care and the power that the health system has as a consumer, there are enormous opportunities to not only do research, but do research that is relevant to the eventual transferring of that research to the marketplace and the creation of new opportunities and new jobs.

For example, just in a simple way, I visited the Baycrest Centre, which has been a pioneer in providing home services to the aged and to the physically disabled. In the work they've been doing, they have researched and developed a number of devices that make it easier for people to live independently. The devices, such as cutlery, plates, simple things, as well as the design of a kitchen, is the kind of work that I think ought not to be confined to the Baycrest Centre, let alone to the province of Ontario, but is the kind of work that we can showcase, that we can market and create new economic opportunities within the province by highlighting and by promoting. The health economic development division will be doing that.

Let me also say, as I look at a health research council, that I'm very cognizant that as we make this shift within our health care system from institutions to more community-based services and to more community health and public health prevention and health promotion, we have an obligation to develop the capacity to be as scientific and as rigorous in our evaluations and in our look at that side of the spectrum as we are on the strictly scientific side of the spectrum and the institutions, which is more easy to count and to evaluate. For example, work that has been done within the ministry to develop a model for the evaluation of community health centres is the kind of research that I think a health research council can also give us assistance on.

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In summary, I am very supportive of the initiatives Dr Dirks has recommended to us. There is a broader framework within which it is being evaluated and reviewed, and I hope before too long to be able to say something publicly and share that valuable report with the members, as well as the public at large.

Mrs Sullivan: Thank you. I will ask for a written response to my next question, which relates to the status of the clinical clerkship stipend for health students. I'd like a report in writing with respect to the dollars that are being spent, the number of students who receive the clerkship stipends, any proposed changes in the funding mechanisms for those stipends.

I would also like, while I have this round, to move on to the legal services division, which is also in the same vote, and ask, first of all, what is the status of the regulations with respect to the consent to treatment bill, and will those regulations be distributed to interest groups for comment before they are brought into force?

Hon Mrs Grier: I saw Gilbert Sharpe, who is the head of our legal services branch, here a few moments ago. Has Mr Sharpe left or will he be returning?

Interjection: He stepped out. I'll see if I can locate him for you.

Hon Mrs Grier: I don't know quite what the status of those regulations is at this point, but I'd be happy to get that information and have Mr Sharpe answer it this afternoon.

The Chair: Okay. We'll pick that up in the next rotation. I'd like to move to Mr Wilson.

Mr Jim Wilson: I appreciate the opportunity, Minister, to ask you a few questions this afternoon. With the debate that's been going on surrounding Bill 50 in the Legislature of late and the hundreds of letters and petitions we've received with respect to the issue of psychoanalysis and the intention, we believe, of your government to limit access to psychoanalysis, to limit the extent of treatment an individual patient may require in terms of the number of times a patient may visit a physician for psychoanalysis, I'm just wondering if you can enlighten us on what the status of that discussion is within your ministry. As you know, there's a great deal of concern, and here in the committee room today we have people from the mental health community who are very much worried about the future of psychoanalysis in this province.

Hon Mrs Grier: I certainly am aware of the concern of the people who are here today and who have been following the debate on Bill 50 in the Legislature. I had the opportunity to meet with them earlier this week, and I know that my predecessor, Frances Lankin, had extensive discussions with them, and we understand fully their concerns.

I'm reluctant to be more definitive today about that specific procedure, but let me very clear, as I was in my opening remarks, that it is not the intent of the Ministry of Health to practise medicine or to determine unilaterally what is medically necessary. That is an ongoing debate and is something that we have found is most productively discussed under the auspices of the joint management committee, so any discussions about the delisting or the limitation of payments under OHIP for procedures have always in the past been discussed with the JMC, and will be in the future. We see that as a very valuable opportunity to do that.

Having said that, we have in the past, in conjunction with the JMC, looked at the practices in other provinces, particularly with respect to psychoanalysis and psychotherapy, and accepted the recommendation that there should be a differentiation in billing between psychotherapy and psychoanalysis so that there is a greater ability to determine which of those codes is being used by whom so we can more effectively monitor and manage the system.

Beyond that, as that was one of the issues we had put before the profession as part of our expenditure control plan and, as the members of the committee are aware, the negotiations that are ongoing with the mediator and with the Ontario Medical Association are considering in one package both the proposals under the expenditure control plan as well as the objectives of the social contract, all of this is under discussion with the OMA. What we have said to them is that we have a target figure which has been accepted by both sides in those negotiations as the saving we have to achieve.

The way in which that saving is achieved, of course, we want to do in consultation with them, and I remain optimistic that as a result of those discussions, we will have an agreement with the OMA by August 1. Whether that will reflect the initial proposals that we had made under the expenditure control plan or whether the saving will be achieved in a different way, it is both too early for me to say and inappropriate for me to comment upon.

Mr Jim Wilson: If you really wanted to protect the status quo in psychoanalysis, you would simply exempt that from your part of the negotiations at the JMC. Have you done that? If not, why not?

Hon Mrs Grier: Because, as the member has said so often, the minister should not be practising medicine, and the minister, in consultation with the OMA, wishes to discuss what procedures are medically necessary and the extent to which the insurance plan should cover the costs of procedures and how that is going to be administered. That is the process upon which we are engaged at the moment.

Mr Jim Wilson: I don't think the JMC discussions should be so secretive. To what extent has psychoanalysis in particular been discussed at the JMC, and what's the status? What's your feeling from those meetings? Is it going to be delisted or limited? I think the public has a right to know.

Bill 50 is so general in the sweeping powers that you want, and the only delistings that have been identified to date -- the primary one that's come to the public's attention is psychoanalysis. I think as politicians we have received a very strong opinion, a very loud outcry, from the public that they want to see psychoanalysis protected. While I certainly don't encourage you -- I agree with your comments -- to practise medicine, I do encourage you to use influence with the JMC to ensure it's thoroughly reviewed. I assume it's being thoroughly reviewed, and if it is, what seems to be the status of psychoanalysis at the JMC meetings right now?

Hon Mrs Grier: With respect to the JMC, the JMC had a working group that looked at this procedure and has reported and discussed it thoroughly. The ministry then suggested a limitation on intensive psychoanalysis as part of our expenditure control plan.

Mr Jim Wilson: So the ministry suggested that. Before, you said you aren't playing doctor. Now you're saying it is possible for the ministry to make suggestions with respect to medically necessary treatments.

Hon Mrs Grier: For discussion with the Ontario Medical Association. The JMC has discussions; the JMC makes recommendations; the JMC does some analysis and does some research. There is then the discussion on actual fee-for-service under the economic agreement that occurs with the OMA. That's what's happening now, and as part of that, some issues that are discussed at the JMC are put on that table, and some may not be. We chose to put that particular issue into those negotiations. Those negotiations are ongoing, and beyond that I'm not prepared to comment or to negotiate in this forum.

Mr Jim Wilson: Then I just want to ask you, what else did you put on the table at the JMC? You've admitted to psychoanalysis; we've heard rumours about many others. I gather, because of your admission, that it would be public and appropriate to tell us what else you had put on the table. What other surprises is the public in for?

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Hon Mrs Grier: All of the issues under the expenditure control plan were released I think in April or May by the Treasurer as part of that and are very much public knowledge; the question of standard eye tests once a year, the delisting of tattoo removal and a number of non-medically necessary procedures. I can get that list. I haven't got it in front of me at the moment, but I'm sure the member probably knows it off by heart better than I do.

Mr Jim Wilson: Where I have a problem, and it's been a problem when I've been trying to debate Bill 50, is that you've already predetermined that eye tests, psychoanalysis and tattoos are non-medically necessary -- you just said that -- and that's why you put them on the table. You told me in your first answer, though, that that was the whole point of the JMC analysis and negotiations and that you aren't prepared to negotiate that now.

It seems to me your ministry has predetermined what's medically necessary and what isn't. Part of the lobbying effort now on behalf of psychoanalysis is exactly that: They're trying to prove the point that they are medically necessary, and who in their right mind said it wasn't a medically necessary procedure? You've just admitted that those were put on the table by your ministry as non-medically necessary procedures. If I sound confused, you should see how confused the public is out there. I want a response to that.

Furthermore, Minister, after the expenditure control plan of April 23, we then had Bill 50 and Bill 48, social contract. When we saw the actual wording of Bill 50, we didn't see the specifics of the delistings, ie, we didn't see psychoanalysis actually named in Bill 50; we just saw sweeping powers. So the public says: "Wow, they've already unilaterally determined what's non-medically necessary. What else is in their bag of tricks, and what else are they planning on delisting?" I think the public has a right to know. My opinion would be that the way you've gone about this with the JMC is that the people who aren't at the table are the patients themselves, and it's a fundamental flaw in the process.

We've seen other jurisdictions, if you want to quote other provinces. They've tried, and certainly some states have tried, to include the public more and ask the public what it feels is medically necessary. That's what's missing and that's what's frustrating about your government's whole approach to health care reform.

I'd like a clarification on this non-medically necessary. It seems to me you put the cart before the horse in a number of circumstances, and there's mass confusion out there.

Hon Mrs Grier: I disagree that there is mass confusion.

Mr Jim Wilson: Well, answer my phone.

Hon Mrs Grier: There are a number of issues where there was discussion at the JMC as to whether or not they were considered medically necessary. The extent of psychoanalysis was one of those. As part of our expenditure control plan, we listed many of those items as proposals about where we could constrain our costs. All of that discussion has now been encompassed in the negotiations with the Ontario Medical Association.

As a result of those discussions and whatever is negotiated there, we will be in a position to say quite clearly what will be delisted and what will not be delisted and what will be constrained and what will not be constrained. Bill 50 is the mechanism that is going to enable the implementation of those negotiations.

In previous years' negotiations, there were often issues that were discussed for which there was no implementation mechanism, and I would point out to the member that if he reads the Health Insurance Act he will find there are many powers within that piece of legislation that enable the minister to decide what's paid for and what's not paid for, what's insured and what isn't insured. The proposals in Bill 50 are very much a clarification of that, as opposed to the kind of draconian dictatorship that I know it is in the member's interest to portray this legislation as.

But I want to talk about the member's final point, which I think is a very interesting one, and that is the role of the consumer in these discussions, because that is certainly a concern I have. There is a great desire on the part of many of the professions to negotiate bilaterally with the ministry and to have the privileges that have been afforded to the medical profession with both the Rand formula and the joint management committee and the structures that have been established under the framework agreement.

In my opening comments to this committee and in my final comments today, I think I've made it very clear, as this government does time and again, that we see health care as being more than medical care, which is why enhancement of the role of the district health councils, involvement of consumers and having a broader range of players in the discussions of the kind of care that is to be provided in any one community are very important to us. I really share the member's concern about that and would welcome some constructive discussion at some point about how his objective, which I share, can be accomplished and what kind of structures we require to do that.

The Premier's Council on Health Strategy, which was established by the previous government, has been built upon by us and is a very useful vehicle for broad policy discussion. When you want to get to the next level of detail, there aren't the same mechanisms. We've been doing it on a regional basis with DHCs, but we obviously need it also on a provincial basis. I think no jurisdiction has yet resolved that issue, and it's time that Ontario began to talk about it. I certainly welcome his attendance at those discussions.

Mr Jim Wilson: Briefly, I take exception to the minister's comments with respect to my concerns about Bill 50. My concerns are shared by the medical profession and most of the regulated health professions. I didn't make them up. I also have a fairly extensive background in health care, having worked at both the federal and provincial levels in health care. I'm very familiar with the Health Insurance Act. The reason you have Bill 50 is not that it's a clarification of the act, although that's a nice word; it's an expansion of the government's powers with respect to the issues you delineated yourself. Otherwise, you wouldn't need Bill 50, if you didn't want expanded powers. If you think it's simply a clarification and a redundant piece of legislation, then withdraw it. I'd be perfectly happy and I wouldn't have to go up there at 6 o'clock and debate it once again.

With respect to consumers, I know that you personally -- and I give you credit for that: You have a long history, and I've spent many a night reading your history, some of it quite entertaining and much of it on behalf of consumers in health care. My only suggestion to you is that rather than the approach you're taking now with Bill 50, with Bill 48, with Bill 29, which I understand is split out now with respect to pharmacists, I think it's unfair to the public to allow changes in health care to occur basically through the media. The media pick up, or critics pick up, or your expenditure control plan, to be fair, floats out a few things you might delist. Then it's up to individuals like those in the room here today to lobby the government, to spend their own time, money, energy and postage stamps trying to get meetings with you, trying to get the message out to the public with respect to, for example, psychoanalysis. I don't think that's the approach.

Although I'm not wholeheartedly in support of the Oregon plan, I like the approach they took over five years in truly trying to reform their health care system, in having full public panel discussions, exhaustive public discussions, not looking at simply a dollar-slash-and-burn approach to health care but a true reform of the system. That's what I would envision as true health care reform.

It's probably one of the reasons that other governments weren't able to do true health care reform, because they weren't willing to take the time to do that. The slash-and-burn approach to health care does leave the consumer out; you do it behind closed doors. We will find out after your JMC/OMA negotiations what exactly is considered a medically necessary service and what isn't. In the meantime, the public has to sort of batter down your door and try to get your ear with respect to different issues that are floated out that might be delisted. I don't think that's an appropriate way to reform our health care system. It's unfair to the public.

District health councils may be fine, the Premier's council on health may be fine, but I don't think there's anything to replace panels of citizens, just people who are in health care services now, discussing it before the fact. A lot of the stuff you've given the district health councils, up to until recently, was after the fact. Even, I would say, on long-term care you're giving them marching orders to design local programs, but essentially things have been decided ahead of time; that not being the best example, because there were public forums.

But certainly Bill 50 and delistings are, I think, a prime example of where the public isn't at the table and the government's making unilateral decisions. You know you're getting in trouble down the road: You've exempted yourself in Bill 50 from legal liability for anything that might happen in the future.

Those would be my comments. I give the floor to my colleague Mr Carr.

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Hon Mrs Grier: Mr Chair, let me comment on that.

The Chair: In fairness, let the minister give a brief response, and hopefully there'll be time for Mr Carr.

Hon Mrs Grier: I think in his comments the member does a disservice to the many thousands of people across this province who have participated in discussing health care reform. He talks about a specific element of the health care system, psychoanalysis, and from that extrapolates into a unilateral decision to reform the health care system.

I remind him of what I've already said before this committee, of years of reports, studies, analyses of health care, culminating in a vision of health care and in some very specific goals from the Premier's council which were adopted by the Ministry of Health as the vision and the approach and the goals that we want to take as we look to better management, better delivery and a better health care system in the future.

Within that, instead of the Oregon approach of an across-the-board discussion on health care, the discussion has focused on various elements of that: long-term care, mental health reform, now drug benefit reform, all of the things with which the member is very familiar.

Another aspect has been OHIP, which is the insurance part of health care, and how we constrain if not reduce the costs within OHIP. Within that, he's right. There has not been a broad consultation around that. It has been historically something that I think was decided almost unilaterally by the profession.

Under our government, an agreement was reached with the profession and some mechanisms put in place by which there would be bilateral discussions. He has now suggested that we need to go beyond that into more general discussions in a more formalized way than in the discussions that occur in this House and in public.

To say that health reform is driven by the media is completely wrong. To say that we have only come up with a list of expenditure reductions and then dealt with the OMA exclusively on that denies the fact that these were released by the Treasurer for I think the first time as a measure of expenditure reductions that were in fact going to be discussed and, as I said at the beginning, diminishes the importance of the participation of the people of this province in a reforming of health care so that we have a health care system that the taxpayers can afford in the future.

Mr Gary Carr (Oakville South): I have a quick question. It's basically a follow-up to our private discussions last week regarding the situation with brain injuries and head injuries. For those who aren't aware, I raised a particular instance of an individual who is in Texas now at a cost of about $1,400 per day, I guess. There's some concern about the family bringing that person back, and I gave you some of the details. I was wondering, as it relates to this case and to brain and head injuries in general, have you been able to decide what the ministry plans on doing in cases like this?

Hon Mrs Grier: I know that this has certainly been an issue as we looked at the expenditures for out of country. This was an area where there were in fact major expenditures occurring and where the reinvestment and the establishment of both facilities and experts for rehabilitation within Ontario were very much a priority.

Just recently, we announced the expansion of services in Hamilton for children who have had acquired brain injury, and there has been an approval of over $3 million to hospitals in Toronto, Sudbury and Thunder Bay with respect to that.

In 1992 I'm told that the supplementary budget for Health stated that $9 million of new resources would be devoted to acquired brain injury treatment and community care, so the $3.08 million that I mentioned for Toronto, Sudbury and Thunder Bay was the final part of that $9 million. That flowed from the recommendations of an internal ministry work group that had looked at both hospitals and community programs.

The specific case you referred to in Hamilton or in your constituency, I am aware of. I'm afraid I don't at this point have details of where that particular request for repatriation stands.

Mr Carr: What about the funding for the Willett Hospital? What is the status of that? Could you update us on that?

Hon Mrs Grier: My last information on that, and I stand to be corrected by the people in the room, was that a formal application for consideration of that facility as an independent health facility had not yet been received. That was a couple of weeks ago, so perhaps I could clarify that and get back to you tomorrow.

The Chair: Mr Carr, One of those constituent concerns is one of my constituents and I'd like to pursue it, but I'm really required to proceed to the next caucus.

Mr Gilles Bisson (Cochrane South): Just for clarification, I take it there are a few other members. I guess that gives me about five, seven minutes?

I'd just like, first of all, to thank the minister for obviously appearing before this committee in order to present her estimates for the Ministry of Health. I take it being Minister of Health these days is at best not an easy task, having to deal with the pent-up demand and the pent-up want within the health care service across Ontario that's been building over the years. Some of the things that quite frankly are needed in the health care sector need to be expanded on at a time when there's not a heck of a lot of money out there, and it's not an easy job to say the least.

I'd like to ask a couple of questions, basically maybe try to demystify some of the things that we're hearing out there. I guess about a month ago, there was a campaign going on about the province. I know it was certainly happening up in my riding, up around Timmins, where doctors were talking about exactly the delisting of services within the OHIP schedule.

Some of the things that were listed -- for example, in the paper was a young boy who has an earache can't appear at the hospital or can't appear to the doctor more than once a year because the bad old Minister of Health was going to take that away from him, basically emergency wards would all have to be shut down. I'm wondering if you just can clarify some of that and explain maybe in concise forms exactly what's happening with the expenditure control plan and how the whole issue of delisting is working so that people can better understand what that process is all about and what actually is intended.

Hon Mrs Grier: Yes, let me address that very specifically because certainly the advertisement that said that if your child had a severe earache you may not get treatment really worried me, as a grandmother of a little boy who has in the past had severe earaches.

The suggestion that a professional physician or a hospital would not provide care to somebody in need appals me. Of course, nothing that we have done as we look at ways to manage the system and to constrain costs deals with medically necessary services. As you heard in my exchange with the previous member, there is debate about what is medically necessary and what is not medically necessary.

I don't intend to practise medicine, but anybody can tell you that a child with a severe earache needs help, and I think it is generally accepted that something to deal with the earache is medically necessary. You don't surely have to be a physician or make any apologies as a politician for saying that's medically necessary.

So for physicians to suggest that somehow that kind of a procedure might not be paid for, I think calls into question whether we're talking about the quality of health care or the amount that is going to be paid to the practitioners within the health care system, which is what the current debate is in fact really all about.

As I said to the member for Simcoe West, the status of suggestions as to changes in the regulations governing what is in fact covered by the province's insurance system, OHIP, and what is not covered by the province's insurance system, are under negotiation with the Ontario Medical Association at this time.

The way in which those are dealt with is by discussion at the joint management committee, which is representatives from the OMA and from the ministry, and is then concluded in the economic fee schedule forum with the OMA at which time after that amendments are made to the regulations.

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Mr Bisson: In short, we're looking at services that are hopefully not essential services, where people wouldn't have to require service on regular medical --

Hon Mrs Grier: We have the Canada Health Act, which provides across the country that medically necessary services are available and accessible to all of the people of Canada. We have a system in Ontario where we haven't in fact provided that service. I suspect that a child with an earache in my constituency would find it easier to find a doctor than in some of the remote parts of your constituency.

What we've been trying to do as we look at better delivering those services to all the people of the province is examining how we now deliver them and seeing whether there are some services we currently pay for that in fact we can cease to pay for so that we can provide all of the medically necessary ones to all of the people of the province.

Mr Bisson: I just want to bring to you probably something that you've already heard and that probably every other member can share. What strikes me, as we go around the province of Ontario, work within our own ridings and talk to our constituents around the question of health care, is that I think all of us on all sides of the House agree that the health care system we have in Ontario is second to none and something we want to preserve. Certainly we're working, I think all of us, under that premise.

But I think we all recognize that there are problems in how much money we spend in the health care sector. In some areas we spend more money than we should; in other areas we don't spend enough. I'll give you an example. We have a hospital in Timmins, the St Mary's Hospital, now the Timmins and District Hospital, which acts as a district hospital for the district of Cochrane, which encompasses communities all the way up to the James Bay coast. Unfortunately, the way that particular hospital is funded is basically as a community hospital is my understanding.

I'm led to believe, if I believe what I've been told by some people in the community, that the way we fund our hospitals in some cases is that we fund for services that are actually not even being provided, which would lead you to believe that what's happening, in short, is that a person in a community somewhere, rather than having that service done within that particular community is coming to Timmins because that service is not provided there because of lack of doctors etc, whatever it might be. The hospital in that area is not getting enough money in order to pay for that service while other hospitals in more remote areas actually have surpluses.

I guess what people are really struggling with, I would imagine all over the province, is how can we find a way of trying to get people to sort of let go a little bit and say, yes, we need to recognize that health care dollars are very scarce and we need to find a way to make sure that all of those dollars are properly spent and that we have a better sharing of dollars. That seems to be the big frustration out there, because people are just having a really hard time trying to deal with it.

Two other things on the question of cost: People also ask themselves a very simple question. They say: "We see the government trying to deal with the question of cost. We agree with that." But we look at some of the things that are perceived as being big ticket items as far as how we waste money is concerned and we don't see the government moving on them.

One of the ones that comes up, as we've heard in the Legislature before, is the question of health cards. People have the impression, depending on whose figures you look at, that there is anywhere from $20 million on the low side to $700 million on the high side of fraud through the health card system. I know there have been some studies, but what are we doing as far as concrete steps are concerned in order to try to prevent that from happening if it's $20 million or $700 million?

Hon Mrs Grier: Let me respond in reverse order to the questions. I'll ask the assistant deputy minister to respond to the hospital one in a moment.

The health card one comes up again and again. I think it's important that I say again and again that for many years there were numbers in this province. We think there were 25 million people out there who allegedly had a health number and were able to get access to the health care system.

The Peterson government brought in the health card early in 1990 and made the decision, in light of the facts available to it at that time, that what was required was a very simple transition where there was no intensive application process and the risk of somebody not being covered in an interregnum period, and so very simple questions were asked -- your name, address, sex and date of birth -- and you were given a health card. The result was that more health cards went out and have continued to go out than perhaps there are people.

A year ago we set up within OHIP a registration branch to specifically begin to do some studies and find out the extent of the improper use. Some of it is fraud, and it all gets called fraud; some of it is improper billing by physicians. One of the things in Bill 50 is an expansion of the number of medical review committees so that we can more investigate improper billings. There are a variety of reasons why there is misuse of the health card. Fraud is one of them.

We believe the extent of that misuse is about $20 million. We think the registration branch is moving effectively to deal with that. We think we can be more effective, so we're looking at what it would cost and what would be involved in going to a more sophisticated card that perhaps had a renewal on it. I think Mr Morin -- the member for Ottawa East, is it? -- has a bill before the House with respect to a photo, and we've been looking at that. There's the experiment in the north with one that has a microchip that gives your health record as well. That raises issues of confidentiality.

But certainly we're looking at better management of that, better investigation. The member for Simcoe West, I'm sure, is going to give me shortly some information to back up his claim yesterday that 400 cards had been sent out to one point.

Mr Jim Wilson: We've already given it.

Hon Mrs Grier: We have been unable to get from him so far the name of the doctor, the address and the area where that occurred. When we get complaints, we want to move more quickly to address them, but we can't just go on rumour; we have to have some facts so that we can investigate and verify it. I want to increase our capacity to do that.

With respect to the nub of health care management, which I think you addressed in your first question, which is, "How do we have the most appropriate services and the most appropriate funding to the areas that need them?" I go back to my desire to see more regional involvement in management and planning through district health councils. Mrs Mottershead, who has been dealing with that funding for longer years than I have, can perhaps speak specifically to the issues you raise in your question.

Mr Bisson: I just want to be clear. I'm talking about the fact that if you have two hospitals, one in a small area, you might be paying, let's say, for obstetrics where obstetrics is actually not performed and is being done in a regional hospital somewhere else that doesn't get the adequate funding because everybody's referring in. That's what I'm wondering about.

Mrs Margaret Mottershead: I'd like, before I respond to that, to put the funding issue in a context for you. In 1982 there was a major shift in the funding of hospitals, from a line-by-line full budget that gave an accounting of where the money was being spent in terms of what departments, what procedures, what clinical programs and so on, switched to global budgeting. Global budgeting has recognized the static nature of the operating budget, with the annual increases due to cost escalation and program expansion and other factors.

In 1991 the government recognized that there were some fundamental flaws -- and I believe your case is one in point -- to the whole funding issue. It initiated a program review of hospitals funding, which had in the committee every single stakeholder in the hospital setting, from front-line worker to departmental level to CEOs to trustees and actually quite a comprehensive stakeholder group, who reviewed all the elements of funding and some of the problems inherent in that.

As a result of that, the government announced a three- to five-year multi-year plan for reform which led to two things specifically: One is the establishment of the operating guidelines for hospitals to be directed by the DHC, to make sure there is recognition of services being provided in a number of centres by different hospitals and to try to rationalize some of those services; and also the establishment of the JPPC, the joint policy and planning committee, a committee that will be looking directly at some of the funding issues, particularly the issue of reallocation that recognizes that services are being taken out from a local area to a regional setting. In fact, some of the referral patterns are changing, and you have to recognize and pay for the services where they are being utilized.

Mr Bisson: I think other members of my caucus have questions.

The Chair: There are about three minutes left for Mr O'Connor.

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Mr Larry O'Connor (Durham-York): Minister, I've got a question that my constituents have posed to me, and perhaps you could help them out: my constituents up in the Georgina area who are serviced by Dr Patricia Marchuk, out of the family clinic in Pefferlaw, Ontario.

The difficulty she has right now, through the expenditure control plan and the capping in services -- she's soon to become the only physician servicing that area. There is some sharing of physician services for Beaverton, and they're trying to bring Cannington into the picture; they're trying to negotiate a way of servicing each other and helping each other out. This rural area I represent isn't classified as an underserviced area, but through the cap is going to be put in a situation where the after-hours services and emergency services to the area could be limited.

I guess part of the problem is that we need to get more physicians out into the rural areas. Pefferlaw's not that far from downtown Toronto, but to get the doctors to come into rural Ontario is really quite difficult. I wondered if you might be able to help me explain to my constituents what you as the minister have been doing to try to get doctors into the rural parts of the province, especially the constituents who have been sending me the letters, who use the services from the Pefferlaw health clinic.

Hon Mrs Grier: I think the member has raised an issue that has bedeviled Health ministers for 20 years, how to provide adequate coverage to underserviced areas of the province. When we say "underserviced areas," we tend to think of the north, but as your constituency, which is part of the greater Toronto area, demonstrates, there are areas that are short of doctors that are very close to major urban centres, which may be part of what mitigates against your area: Because you're so close to Toronto, that is where physicians prefer to practise.

I don't think it's only money. To some degree, it's lifestyle: people who want to live in rural areas and people who don't, and people who want to practise medicine in the comparative isolation of rural areas as opposed to in an urban core, where there are backups and specialists. We've gone from the general practitioner/family physician who did everything to a much more specialized kind of medicine. Not all general practitioners feel comfortable practising in isolation, though I agree with you, Georgina and Pefferlaw are not exactly as isolated as the constituency of the member who spoke before you.

I think the solution is looking at the question generally: how we can provide support to doctors in rural areas, as well as looking at the income level. Part of the question they are now raising as we discuss with them limitations on the amount of billing that a general practitioner can have is: "Okay, if there's a limitation, then I'm not going to be doing after-hours and emergency work, because it isn't worth it. I'm not going to be paid for doing that work."

I think the fee-for-service system has not helped us in addressing those issues and that as we look at providing a more consistent level of care around the province, we have to address alternative payment plans. In some rural areas, for example Mount Forest, northwest of Metro, the physicians and the hospital and areas have come together and looked at a global budget where there are salaries and alternative ways of paying for people in order to ensure 24-hour coverage. There are a number of different models that are being looked at.

As part of addressing the whole question of underserviced areas, we established some months ago a committee that is known as PCCPME. The title eludes me, but it's a coordinating committee for post-graduate medical education, chaired by Dr John Evans, an eminent policy person as well as a physician. A task group of that, chaired by Bob McMurtry, the dean of medicine at Western, is looking at this specific problem and looking at innovations such as the academic health science centres working with particular regions to provide the peer support and the backup in order to encourage doctors; and looking at the training, because if you want a doctor to practise in isolation, you have to make sure that as they're trained, they have the additional skills required to do that.

So it's a large problem, it's an old problem, and it's one that cannot be solved by a quick fix. It's one that the current financial incentive program has not really addressed, and it's one that I know your constituents want addressed in a fundamental way. I think some of the discussions in policy development we're now having will move us in that direction.

The Chair: I believe Gilbert Sharpe is here to respond. Please come forward, Mr Sharpe --

Hon Mrs Grier: It was Mrs Sullivan's question that I needed help with.

The Chair: -- to respond to Mrs Sullivan's question with respect to the Consent to Treatment Act. Perhaps Mrs Sullivan might reframe the question, as you were not in the room at the time.

Mrs Sullivan: I suppose Mr Sharpe can only answer the first part of the question, which is, when will the regulations for the Consent to Treatment Act be ready? It will be up to the minister, as the political head of the Ministry of Health, to respond to the second part of the question, with respect to whether or not she will circulate the draft regulations to those groups and organizations which have a special interest in their implementation before they are promulgated.

Hon Mrs Grier: Perhaps if Mr Sharpe could comment on the status of the preparation of regulations, then it might be easier for me to respond to the second part of the question.

Mr Gilbert Sharpe: Sure. First, I'm sorry for not being here when it was asked and having to do things out of order a bit. There are, as you know, a number of regulations being worked on. The most important and the one you're probably thinking about is the assessment of capacity; standards and criteria for doing that. We've been meeting with a number of groups on both the adult capacity issues and the children's side, the children's aid societies and experts in children's mental health, to come up with a set of criteria that would be embraced by the providers and by consumers as well.

That process is going well. In fact, I've just been advised that we have another meeting set up on Thursday to do that. We're hopeful that by mid-fall we'd have a set of draft regulations that might be promulgated generally for discussion and further consultation.

There are a number of other areas for consultation that came out during the hearings on the consent legislation: exceptions from the definition of "treatment;" just how many things would be covered in terms of rights advice having to be given; how broadly the act would be applied; the questions of which controlled acts under RHPA might be excluded from rights advice; definitions of "health practitioner" and others.

The work on those areas has also begun, but frankly, the aggressive work, as I said, has been more on the question of assessments of capacity. I hope by Christmas that we would have a full set of draft regulations ready for consideration and for additional consultation. We do have to meet with many of the newly regulated health professions to work with them on which acts should be excluded.

Mrs Sullivan: Thank you.

Hon Mrs Grier: I think that answers both sides of your question. There's going to be extensive consultation, and the draft regulations will be shared with many of the groups that have been involved in their development to this point.

Mrs Sullivan: Then do I have the minister's commitment that the regulations will not be promulgated until they have been circulated in full to the affected groups and organizations for their comments subsequent to the consultation process that is proceeding now with respect to the drafting?

Hon Mrs Grier: I think Mr Sharpe has described the kind of very open and consultative process that is ongoing. I think I want to see how that proceeds and hope there would be a level of consensus around the regulations. The member certainly has my commitment that the process, as described by Mr Sharpe, will continue and that we want to have as much advice as possible with respect to those regulations.

Mrs Sullivan: As we leave this topic, it was very clear in all of our debates and committee discussions with respect to that bill and the associated pieces of legislation that even a single word can make a substantial difference in the ability of health care practitioners to provide services and of patients to receive the kinds of rights advice or other provisions that they require. Every single group and organization, I underline to the minister, that appeared before the committee made specific requests that before the final regulations in the final stage were promulgated, they would be able to see those draft regulations and to provide comment that would allow, even if it's a single word that would affect the implementation of that bill -- that that be done. I hope that's your commitment and not simply a commitment to prior consultation before the regulations are drafted.

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Hon Mrs Grier: As the member knows, I was not part of that discussion on that particular legislation. I would certainly benefit from, I think, hearing a broader description from Mr Sharpe as to this consultation, as to who has been involved in it to date and whom you would anticipate being involved in it?

Mrs Sullivan: If I might, could I ask that this be written? I have a number of other questions in other areas. Perhaps Mr Sharpe can come back to us with that information and then we can also circulate it to those who have an interest.

The Chair: It can always be made as a request. Is there any problem with that, Mr Sharpe?

Mr Sharpe: No, not at all.

The Chair: Okay, I appreciate that very much. Please proceed.

Mrs Sullivan: Thank you. I think the minister has learned some good lessons in ragging a puck from Jim Bradley. If I might, I'd like to --

Hon Mrs Grier: I listened for five years.

Mr Jim Wilson: What about Elinor?

Mrs Sullivan: And perhaps from Mrs Caplan as well. But I would like to proceed in my next round with a comment and then get my questions on the table and ask the minister to respond subsequent to my getting my questions out.

My first comment related to the discussion with respect to the delisting of psychotherapy which the minister had with Mr Wilson. I think that it's fair, for the record, to indicate that when the ministry first put the issue of the delisting of portions of psychotherapy or the limitation on psychotherapy on the table and discussions were held, the joint management committee recommended that there should be no change in the service delivery and that there was no consensus with respect to the issues about the billing codes. Indeed, Frances Lankin, who was then Minister of Health, issued a letter indicating that there would be no changes, on recommendation of the JMC.

The concern is that the proposals now included in the expenditure control plan are the very ones which were on the table earlier. It tells us, it tells patients and it tells practitioners that the Ministry of Health is convinced that the services it proposes to delist, or limit the listing of, are not medically necessary.

I have asked the Minister of Health, in order paper questions, for any health outcomes studies which have been prepared with respect to this issue, and the response to that has not been forthcoming. What the proposal on psychotherapy does is to put forward a proposal which would set a quota or ration services which are now considered to be medically necessary. The minister has indicated that this will not be proceeded with unless there is agreement with the JMC. I suggest that if the minister's intent is not to ration services or to establish quotas for services which are medically necessary, whether that's by region, by treatment, by treatment patterns, by the number of times a person receives that treatment, then it is clear that the minister does not need Bill 50 and the minister should withdraw Bill 50.

Having said that, and that's my comment, I would like to move on to two questions, the first being with respect to the role of the boards of directors or trustees or governors of public hospitals in Ontario, who are statutorily required to be accountable for the operations of hospitals and for policy planning therein.

The social contract for the health care sector specifically says, under section 2.2, subsection (f), "In the hospital sector, hospital operating plan responsibilities will be carried out by or under the authority of the JWC," the JWC being a joint working committee which is set up specifically under the sectoral agreement. The JWC will have no accountability for those plans. The boards of directors of hospitals will continue to have accountability.

I'm asking the minister to describe to us where she now sees the accountability of the boards of directors for decisions that are made outside of their purview, and when she intends or if she intends to bring forward new amendments to the Public Hospitals Act, and what her schedule for implementation would be?

Hon Mrs Grier: Let me start by responding to the member's comments with respect to psychotherapy yet again, and let me acknowledge that she is correct. This is an issue that has been discussed more than once, and when it was discussed by my predecessor, a decision was made that in fact there would be no change.

As we, in this budget year, began to look ever more seriously at the expenditures of the Ministry of Health, the question of limitations on the ability of the insurance plan to pay for psychoanalysis was again raised and has again been put on the table for discussion.

There is not agreement as to how much psychoanalysis is in fact medically necessary. Most acute psychiatric emergencies are handled by hospitalization, and patients receiving outpatient psychotherapy are thought to require approximately two hours a week, and there is long-term, ongoing support services available by many non-physician social agencies for psychotherapy.

Patients who require intensive outpatient psychotherapy would be able, under our proposal, to see their physicians more than two hours per week until the maximum of 100 hours is reached, and patients not requiring hospitalization it's believed would rarely exceed this limit. There is some general consensus that long-term frequent psychotherapy is not medically necessary for everyone who may receive it, but I acknowledge that there is not absolute agreement.

In our discussions the other day I don't know whether it was Mrs Sullivan or Mr Wilson said what was happening in other provinces, and I want to correct that by the information we have which is that seven other provinces have specifically deinsured the long-term type of psychotherapy known as psychoanalysis, and that there is agreement generally that psychotherapy beyond 100 hours per year constitutes psychoanalysis, the intensive therapy that is given by psychiatrists.

Of the seven other provinces which deinsured psychoanalysis, only British Columbia has set established limits, which are one hour per day. The other six provinces monitor psychotherapy billings by physicians and investigate physicians whose billing patterns are, in their opinion, excessive, and they consider more than 100 hours per year per patient as excessive.

What we are doing is in fact consistent with the kind of examination of this expenditure that is occurring in other provinces, and as I have said ad nauseam today, is a matter that is currently under discussion with the Ontario Medical Association as we look at a way of reaching both our expenditure control targets and our social contract targets.

The question of hospital boards and amendments to the Public Hospitals Act is one which I have addressed since becoming minister and which is still, let me say to the member, under discussion, so when she asks about when we might anticipate introducing amendments to that act, I'm not in a position to answer specifically, but I would like to ask the assistant deputy minister to comment on the specifics of the role of boards as they are envisaged and as they exist presently.

Mrs Mottershead: I believe Mrs Sullivan's question related to the social contract agreement that has been tabled. I don't have the document in front of me, but from my recollection, if you go to the very first part of that document, I believe on the first page, it is very clear on the accountability of the boards with respect to the governance of their institutions.

The notion of the joint workplace committees isn't a new one. It is taken directly from the guidelines we do have now, which are the operating and planning guidelines for hospitals, and builds on the issue of inclusions by everyone in the workplace in terms of determining hospital planning and budgeting and so on. I don't see that there is a conflict in what is in that document.

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Mrs Sullivan: I have the final document. This is the July 15 document, which several parties have signed and others have not. There is no description of the role of the boards of directors of hospitals included in this document. I've also reviewed the two previous documents and there was none included in those.

If I could go on to my next question. I have a letter which was sent by Bob Reid, chair, and Fred Upshaw, president of the Ontario Public Service Employees Union, to all OPSEU members in the health sector. Written July 20, 1993. It reads:

"Dear Sisters and Brothers:

"On July 15, 1993, OPSEU's health sector bargaining team signed an agreement with the government under the social contract legislation. The agreement protects existing collective agreements, provides expanded training and redeployment opportunities for current employees and provides a $50-million fund to help save jobs in this sector where a large number of workers earn less than the $30,000 low-income cutoff.

"It also sets a timetable for implementation of the Swimmer report whose recommendations for a province-wide ambulance service have long been advocated by OPSEU."

Minister, I'd like to know, do you intend to proceed with the Swimmer report? Is the timetable which the OPSEU members have been told is included in the social contract bill your timetable? How much money are you going to set aside for the implementation of the Swimmer report? When will you start buying out private sector ambulance services and at what cost?

The Chair: In under three minutes.

Hon Mrs Grier: In under three minutes? Well, let me try. The Swimmer report was an examination of all of the ambulance systems across the province by Eugene Swimmer with a recommendation that they all be brought together into one public system. The ministry did an evaluation of what that would cost and found that it would be quite costly, because we would have to buy out the private ambulance systems that now exist. We did not feel that we were in a position to do that.

As part of the social contract discussions, the unions involved brought in a proposal that differed in its estimate of the cost of this from the ministry. When the member reads a letter, which I haven't seen, that indicates that we have agreed to a timetable for implementation of Swimmer, I stand to be corrected, but certainly it was not my impression that this was what had been agreed to at the social contract table.

What we had undertaken to do and what we had already begun to do was to review both the submissions made to us by the unions as well as the figures that had been our ministry's first estimate of what implementation of the Swimmer report would take, and agree with the unions to a formal review of all of that documentation so that we could arrive at some common understanding of what would be involved in implementation, and from there begin to discuss a timetable for implementation. What we have agreed to is a timetable for review rather than a timetable for implementation.

Mrs Sullivan: Then are you committed to the implementation of the Swimmer report as a public policy item?

Hon Mrs Grier: Not at this point.

Mr Jim Wilson: I just want to take the opportunity to clear the record. Minister, you took a swipe with respect to my question in the House yesterday. I just want to inform you, in case you haven't got the memo that's already been prepared for you, that yes, twice -- a week ago yesterday and again on the following Wednesday -- the top bureaucrat in the health card office in Kingston was spoken to by my executive assistant. He was spoken to both in his office and at his home, because at a committee hearing earlier this year, I was given that bureaucrat's home number as he appeared here with the deputy minister.

Frankly, I think I've acted more than responsibly with respect to this matter, because we're trying to dispel, shake off the old-style politics of opposition and I felt it was such a serious allegation with respect to 400 health cards being sent to one individual at one address, that's why a week before raising it in the Legislature, I informed your top bureaucrat. I can't help it if they don't inform you of these things.

Hon Mrs Grier: It was not a question of not informing me. My understanding is that in that conversation, the ministry had not yet had from you the address, the location and the name of the doctor who was making the complaint. If we have the facts, we have got to investigate, and I certainly share your concern that if this is happening, we have to investigate it and we have to prevent it from happening. I am not aware that we have as yet received the information that we need to effectively make sure that this doesn't happen.

Mr Jim Wilson: I would agree in terms of I provided all of the information I had. I don't have some of those specifics and I made it very, very clear. I would think that your ministry, after one week, would at least get back to either myself or my staff, though, and as a public service to the taxpayer. That's why I raised it in the House. They had the information for a whole week. I had no one get back to my office. I felt it was a very serious allegation.

Hon Mrs Grier: Perhaps the member would repeat now for the record what information he has. I want to get to the bottom of this. I'm told that you reported having heard that 400 health cards had gone to one address. As I understand it, you were unable to give the ministry any other details and acknowledged, or your staff acknowledged, that this was a rumour that you had heard. If in fact that's the case, it is very difficult for anyone to identify whether or not this rumour is accurate or inaccurate. I am as anxious as you are to have the facts. So please give us as much as you know about this situation and you have my solemn undertaking that whatever we can do to make sure it is corrected will be done.

Mr Jim Wilson: You're exactly right in what you know about this case, I know about this case. What I resent is your ministry doesn't deny that it didn't happen in the media this morning. They simply turn it all around and Mr Verbeek says that I didn't notify your ministry. None the less, I'm not required to notify your ministry; I simply did it on behalf of the taxpayers.

Hon Mrs Grier: Let's be very clear on this.

The Chair: No, no.

Mr Jim Wilson: No, I'm not required to --

The Chair: Mr Wilson. Excuse me, please. Order.

Interjections.

The Chair: Order, please.

Mr Donald Abel (Wentworth North): Let him talk. Let him go.

The Chair: I might let you go, Mr Abel. Please.

Mr Abel: Let him talk.

The Chair: Please.

Hon Mrs Grier: Repetition of a --

The Chair: Madam Minister, you're out of order, please. I would like to bring the committee to the attention of the Chair.

Mr Abel: You've got a great future with the Toronto Sun, Jim.

The Chair: Mr Abel, please. Without this becoming argumentative, this is estimates and the committee asks questions of the ministry. I wanted to state that for the record. Secondly, I might suggest that it might be helpful if the minister could tell us what information is required in order to report a case of a potential fraud of a health card.

I remind members that we're on TV. Surely the ministry doesn't want to leave an impression that all this information has to be garnered by the public before a case of card fraud had been determined. But I don't wish it to become a debate as to who said what and what was said on a matter that was raised on the floor of the Legislature. I really would prefer if we got back to the questions about the estimates in this regard. Mr Wilson, you have the floor. Please continue.

Mr Jim Wilson: I will ask a question then, Mr Chairman. I will pursue this in the Legislature.

In response to our opening statements today and your response to those, you talked about user fees and you talked about the fact that you don't consider, your government doesn't consider the fees that seniors are required to pay or residents of long-term care facilities are required to pay as user fees with respect to accommodation fees.

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I've had this argument with Mr Bouchard and with previous federal Health ministers, including my own minister when I worked for the Honourable Perrin Beatty, you know and I know there's no definition of a user fee in the Canada Health Act nor is there any delineation of medically necessary services.

I think where my party comes from on this issue and why I think it's an important public debate is that most people I talk to in the public feel that any out-of-pocket expense is a user fee, whether it goes for accommodation, whether it goes for an ambulance ride, whether it goes for a physician's note if you're sick at work and required to have a note that you may or may not get reimbursed from third party insurance. I thought we were beyond this debate on whether or not user fees exist -- this political debate, as I would say -- in our health care system.

I thought we were beyond that because Geoff Quirt and your parliamentary assistant, Mr Wessenger, and a number of other people who sat through committee hearings with respect to Bill 101, the changes to long-term care -- we had I think general admission many, many times and we had specific admission during those committee hearings that, yes, they were user fees, that the public would see any out-of-pocket expenses as user fees.

We actually had many administrators come forward and say: "Yeah, you can call them accommodation costs or whatever. The fact of the matter is, it's the consumer's portion of being in our home. Many of us have global budgets. We run our home based on whatever money comes in, and if you want to divide it up on the books one way or the other, that's fine."

I appreciate the politics of calling them accommodation fees, but I still contend that $150 million of the $647 million that your government is committing to long-term care reform are user fees from the public.

The reason I think it's important we get beyond that debate is it seems to me that's where the public policy with respect to health care has bogged down in political circles. Do we have user fees, do we not have user fees?

For instance, for you to say that the long-term care fees of $38 a day, some $300 to $400 a month for some seniors in increases, are simply accommodation fees, I don't think gives much comfort to the public. It would be like saying in the ambulance fee of, say, $180, which rich or poor in this province -- and your government didn't implement it but it has been there; your government did increase it within months of first coming to office -- you're sent a bill for ambulance services, whether you're a rubby on the street or someone who can afford to pay that bill.

To say that user fee pays for the engine of the ambulance but not for the gasoline, I don't think the public cares one way or the other. They see ambulance services -- and Ms Sullivan and yourself referred to the Swimmer report -- as essential services whether or not it's delineated in one of the many books the Ministry of Health has with respect to medically insured services I think is irrelevant in the public mind.

I would appreciate it if the government would get beyond that debate of user fees or not, admit that they're there, admit that there's millions of dollars in the system now so that we can get to a public debate of where those fees should be appropriately placed.

I think we missed that debate with respect to long-term care. It has come as a shock to a number of seniors who are now paying those new fees. All members have received calls over the past three or four weeks when the new user fees were put in the system and the increased fees that were already there. Many people have phoned us and said, "What the heck is going on?" It came as a complete shock to them.

I'd just like to give you the opportunity to comment on that. My party has said we've got to stop lying to the public and pretending user fees don't exist when 20% of most hospital budgets are made up of user fees. Every hospital administrator I've ever talked to -- when I first started as the critic in the portfolio, I'd always ask them that. They'd say, "Yeah, about 18% or 20% of our budget come in the form of user fees." People are paying these fees because they feel the services are necessary so they'll pay something out of pocket. I think the public discussion should be, where should those fees be appropriately placed in the system?

What we've seen is around the edges an increase in fees by government, and no admission that these are user fees. I'd appreciate your comments on my suggestion that we should have a full public debate. That was our position in the last election, and I recall your party misrepresented my party's position with respect to that.

Hon Mrs Grier: I think this is a discussion that the people of Ontario and the people of Canada are going to have probably for ever, but most intensively in the coming months. I'm very interested in the member's comments, because I was interested yesterday in Prime Minister Campbell's comments that we had to look at what in fact was medically necessary.

I don't think the debate is helped by semantic discussions as to what is a user fee and what is not a user fee; I would agree with you on that. We have a very good health care system. We have a health care system where the costs have been increasing at a rate that the taxpayers can no longer afford, 8% and 9% in the past. We have now constrained that, but even with that constraint, we're spending over $17 billion on health care. That is a third of the provincial budget. That is the second-highest cost per capita in the world and the highest cost per capita of any publicly funded system.

In our initial discussions here last week, I said I was pleased that there was agreement in the remarks by both you and Mrs Sullivan that we were spending within Ontario an adequate amount on health care. The debate has got to be, within that adequate amount, what does the insurance plan pay for? I think that's where, then, the definition of "medically necessary" comes in, because there has to be, if you're going to ask the question of what the insurance plan pays for, some determination as to, does it go on paying for everything?

If you take the position that the public, the users, ought to pay nothing for anything related to health care, then we are accepting that at some point we will be spending almost the entire provincial budget on health care, and we have to make the tradeoff between education, recreation, environment, natural resources, all of those other things. If you accept that $17 billion is an adequate amount to provide good-quality health care for the people of the province of Ontario, then you can have a more focused debate on, within that envelope, what do you spend your money on?

As I look at how to frame the question that way and I look at long-term care -- and I recognize that, as we define long-term care, we're talking about providing the care not only in institutions, as it has been provided in the past, but in fact more and more in people's homes. Where we move the provision of traditional health care, nursing, physiotherapy, from the institutions into people's homes, then we look at, how do we pay for that?

If Mr and Mrs X are living at home and getting nursing, physiotherapy, whatever, Mr and Mrs X are, according to their income, deciding what form their home will take, how expensive it will be and how much they will spend on food. They are, in other words, paying for their own food and their accommodation. Mr and Mrs Y, living in an institution, may be getting the same kind of health care, or the health care, nursing, physiotherapy or medicine appropriate to the level of intervention they require. Does it therefore mean that as they move along that continuum they reach a point where they are absolved of the responsibility of paying for the roof over their heads and their food?

In the past, they've been paying a very broad range of prices for that roof over their heads and their food, from $26 a day to $90 a day. We accepted the principle that everybody pays for the roof over his head and his food, but if you are making those expenditures in an institution, it should be standard, and it should be standard at $38 a day. The nursing care, the physiotherapy, the other traditional health services that you require are provided free of charge whether you're in that institution or, increasingly, when you are not, so if you choose to describe that as a user fee and say that the health insurance plan should be covering it in the institution, then what do I say to the people who are living at home and who are receiving the same intervention and require perhaps the same level of health care? Do we pay for their food and rent as well?

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I don't think that is what you are saying, but somewhere within that discussion, some decisions have to be made, and we've made the decision that accommodation will be paid for based on income, not assets, by those living in institutions. So that's the rationale for what you call a "user fee" in the long-term care system and what I call a "payment for accommodation."

Mr Jim Wilson: Minister, I do appreciate your response. I think it has been more reasonable than what we've seen from your party in the past. What I'm trying to do, what I do in every speech I give throughout the province on health care, is dispel some of the myths. You've been very helpful in doing that in terms of agreeing with me, to a certain extent, that it is an out-of-pocket expense.

The public does see the $38 a day as a user fee. They do see the fee they pay for an ambulance ride as a user fee, or many, many other fees that are paid, out-of-pocket expenses. Even if the public looked for a definition of "user fee" in any of our acts, it doesn't exist.

What I would plead is that in the future perhaps we could have a higher-level debate with respect to this issue, because I just have been fed up for five years.

I saw Mr Bouchard do it. He did an op-ed piece in the Toronto Star two months ago saying Canada has no user fees in its health care system; it was just before the leadership debate. Well, the man's out to lunch, and I told him so. The reason Mr Bouchard doesn't think there are any user fees is that he only delivers, as you know, health care services to native reserves. Essentially, that's the only delivery of services the federal government provides in the area of health care, and there aren't the user fees that we see outside of native reserves. So in his world, the federal government's world of health care, there are no user fees. They did not know, for instance, when I arrived in Ottawa, that people in Ontario are charged for ambulance fees whether they're rich or poor.

Hon Mrs Grier: If they maintained their transfer payments, maybe we wouldn't have to.

Mr Jim Wilson: Well, we could get into that debate. I don't disagree. I'm just trying to edge you along to a more intelligent debate with respect to this issue. When I get letters from the Senior Citizens' Consumer Alliance for Long-Term Care Reform quoting NDP members that user fees don't exist, I go ballistic, because I think that somehow the NDP member is once again propagating mythology. I see Jean Chrétien doing it federally now.

I understand the politics of it very well. I'm guilty myself, in writing some of these speeches for ministers in the past. I just hope we can get beyond that, though, and have the discussion in public of where these fees should be appropriately placed in the system. That was the position of my party in the last election, and I take every opportunity to reiterate that position.

With respect to the $38 a day, the standard fee, could you clarify for us exactly the intent or the reality out there with respect to this? I visited a number of nursing homes in my riding in the last couple of weeks because administrators have called. They have waiting lists now for ward accommodation because, I understand, individuals are not means-tested if they're in semi-private and private; they're not means-tested according to income.

Frankly, I admit I'm somewhat confused on that. I thought it was a means test across the board with respect to income, whether or not you could afford to pay the $38 a day, whether you were in semi-private or private. I went into the Good Samaritan nursing home in Alliston the other day and there's a list on the door of 15 people who have requested to move out of semi-private into ward accommodation, and of course, there isn't enough ward accommodation. In fact, your government is encouraging more semi-private and private and less ward accommodation, or is going to allow more in that direction, and there are a lot of people and families caught where they can't afford the semi-private and private fees.

My understanding after sitting through a month of committee hearings was that you were bringing down the differential. We were told that many, many times, that there would no longer be this great differential between semi-private, private and ward. I wonder if you could just clarify all this for us.

It was not my understanding, and I'm sure Mr Wessenger, who was here with me, and Mrs Sullivan also -- we had many times the minister and ministry officials saying, "We're bringing down the differentials and everybody will pay the same," but when the program actually got put in place, the phone started jumping off the walls because people got a different thing than what we were told -- and what I told my constituents, because the government told me differently.

Hon Mrs Grier: I'm going to ask Mr Ennis and/or Mr Laverty to come forward and address some of those, but I must say that certainly as I became involved in this, I was always of the understanding that it was the standard accommodation fee that was going to be income-tested and that if people wished to pay over and above that for semi-private and private rooms, then of course that would be their choice.

I certainly acknowledge that it has caused and will in the short run cause problems for people who have been perhaps paying the $26-a-day standard and were therefore able to afford semi-private or private and now find that with the increase to $38 they're unable to do that. But I would remind you that there are many other people who have been in standard paying much more than $38 who have seen their per diems decrease. We have of course not had very many letters or phone calls saying, "Thank you, thank you," from those people, but we have, I think, all of us heard from those people whose rates have gone up.

We have with us Mr Michael Ennis and Mr Patrick Laverty from the ministry.

The Chair: Gentlemen, welcome. If you could give us your title within the ministry and please respond to the question.

Mr Michael Ennis: Perhaps I will respond first. I'm Michael Ennis, assistant deputy minister of population health and community services.

Mr Patrick Laverty: I'm Patrick Laverty, the director of long-term care policy.

Mr Jim Wilson: Could you do this in two minutes or less?

Hon Mrs Grier: You've said it all before, before committee.

Mr Ennis: I'll do it very quickly. The fact is that before we introduced the change in the basic rate, many individuals in nursing homes and homes for the aged were already paying very different rates, rates going from $30 to $40 a day to $90 a day, so there was a differential rate already in the system at the time.

The Chair: Is that the total payment, Mr Ennis, or is that just the portion which the province subsidized, and in each there was a wide variance?

Mr Ennis: Yes. In some cases, the up to $90 a day would be for individuals who were in municipal homes, for example, where they were awaiting an extended-care certificate and did not have one so therefore they were paying the full cost of care; that would be where the higher end of the range would be. I've included both nursing homes, where the extended-care rate was available across all homes, and municipal and charitable homes, where in some cases it was residential care, where you paid the full cost, or where you had a subsidized cost by the government when you had extended-care rate.

In terms of the actual increases themselves, they've applied not only to the basic rate but to those individuals who were already in semi-private, already paying more, and those who were in private, also paying more. With the change in rate, the individuals who were paying more -- yes, they would have a greater demand on the resources because the base has moved up upon which they were operating.

I can give you a very quick example on that. Someone who was in a semi-private accommodation previously would have been paying $36 a day, and now in the new system the semi-private would be roughly $10 more. I think that's the issue you have been addressing, in terms of additional pressure on the individual.

We have given guidance to the operators of nursing homes and homes for the aged that where a hardship occurs, they are to sit down with the individual and the family to evaluate their income and to determine and set an appropriate level they can pay in order that they don't have to move, so that they won't have to move from semi-private into ward accommodation. That's the approach we're giving them at this point in time.

Mr Jim Wilson: If I could just interrupt, that's the crux of the problem. I appreciate some flexibility with respect to individual negotiations, but we were led to believe, and the ministers have made many blanket statements. that everybody would be means-tested. Many of our homes, according to the old regulations, have these large populations of semi-private and private. They all thought they were going to be means-tested. They're not being means-tested, except on an individual basis where hardship has occurred and there's a great uproar from the family. Is that true? And you are automatically means-tested if you're currently in a ward.

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Mr Ennis: That's correct. If I could turn to Patrick to answer the means test, because he's been dealing directly with that.

Mr Laverty: It's not, strictly speaking, a means test; it's an income test, based only on your income rather than income and assets. That is applied for people who are in ward accommodation. At this point in time, it does not apply with regard to preferred accommodation, but we are, as you are, receiving representations on that matter.

Mr Jim Wilson: Thank you for your responses. If I may, Minister, that's where the confusion comes from. We saw in press releases and we saw in many speeches from your predecessor that every senior in the province was going to be income-tested. There was no indication out there that thousands and thousands of seniors who may be stuck in semi-private or private accommodation because there is no ward accommodation in the home -- they certainly had no warning that this was coming, so to say that this system is fair to all seniors I think was an exaggeration.

Frankly, I think our committee hearings were misled on that. That was never made clear in well over a month of four-day-a-week committee hearings, in spite of Mrs Sullivan and me asking those questions. I just express my disappointment for the record.

Hon Mrs Grier: Let me respond to that. I forget whether the committee hearings were in progress when I became minister or whether they were about to --

The Chair: No, they weren't. They were finished.

Hon Mrs Grier: They were finished. But there certainly has been no change in policy with respect to that, so the intent of an income test for people in standard accommodation -- I'm sure I'm correct -- is what the original assumption was upon which the program was based. In fact, when you go back to the original discussion document that was released even before the change in government, the $150 million as a contribution to the program from the accommodation costs was built into the overall calculations of what the program would cost.

The Chair: Perhaps with the permission of the committee, it might allow the Chair to ask a question if it's deducted from my caucus's time. Do I have concurrence?

Hon Mrs Grier: I agree, Mr Chair.

Mr Jim Wilson: Go ahead.

The Chair: I'll be very brief. I attended the public hearings in the city of London when Mr Quirt was present. I raised a question about this legislation: Specifically, I raised the concern about changing the mix of preferred from basic accommodation. As we all have established, if we're not income-testing persons in preferred accommodation but only in basic, we could potentially have a system where nursing homes or homes for the aged could increase the percentage of beds of preferred accommodation. In a sense, if you use the private market analogy, you could convert to luxury apartments and increase your income. This is something hospitals are doing. We were trying to protect that the available stock of extended-care beds didn't become more exclusive or preferred.

When I asked that question, I was assured by the ministry that the regulations would speak directly to not changing that ratio, that we wouldn't be allowed to change the mix. That occurred in the city of London. I asked the question.

I received a letter from Mr Quirt, representing the long-term care division of the Ministry of Health, wherein he advised operators -- I don't have the letter in front of me, but the letter was dated somewhere around July 13 or 17.

Mr Jim Wilson: July 13.

The Chair: Thank you, Mr Wilson. In it, he says that the ratio of preferred accommodation could be increased by operators from 45% to 65%. This, in my view, is akin to conversion to luxury or more expensive accommodation that is not income-tested. That concerned me.

I didn't rule the "misleading" comment out of order, but it did raise some confusion. Why did the ministry change its assertion to the committee in London earlier this year, and then with regulations, after the bill was implemented, allow for a process to change the more luxury or preferred accommodation mix within institutions across Ontario? I appreciate the indulgence of the committee for allowing me to ask that question on behalf of my constituents. Can anyone enlighten me as to why we changed our policy or the stated intention of the government from six months ago to its implementation for July 1?

Mr Laverty: I'm not in a position to indicate what Mr Quirt said in London. We will check the --

The Chair: You were present as well.

Mr Laverty: Not in London.

The Chair: Not the London trip? I apologize. I know you shadowed us extensively.

Mr Laverty: So I'm really not able to answer directly to your question with regard to what the statements he may have made in London were and whether those were inconsistent with the final result.

The Chair: Could someone explain to me why we're allowing the increase in the ratio of expensive accommodation when you've indicated that you've created a mechanism for people to apply for ward accommodation, at the same time allowing a mechanism to reduce the supply of ward accommodation throughout Ontario? It seems to be two different messages, and I'm wondering which is the operative or primary message here.

Mr Laverty: There are two changes with regard to the preferred differential. One of them is with regard to the percentage of beds that may in fact be preferred and the other one is with regard to the premium differential between basic accommodation and preferred.

In fact, what we have is a movement in the differential for semi-private from the previous $9.88-a-day differential down to an $8 differential, and with regard to private, from a $19.78 differential down to an $18 differential. That relates also to Mr Wilson's earlier question about the explanations that Mr Quirt had given with regard to a reduction in the differentials between preferred accommodation and accommodation which is ward accommodation.

The other movement is as you indicate with regard to the possibility indicated in Mr Quirt's letter to the facilities that the percentage might indeed change.

The Chair: Thank you for the indulgence of the committee, and your response, Mr Laverty. Mr O'Connor had not completed a series of questions he was presenting in his rotation. I have no other members of your caucus. Ms Haeck? Mr O'Connor, were you finished?

Mr O'Connor: Maybe I could just then expand on some of the line of questioning that we've been following just briefly for verification.

Minister, the commitment was made by the government for the integrated homemaker service. In fact the announcements were made on the Durham side of my riding, in Durham region. The announcement was made of $931,000 in additional funding, and of course on the York side of my riding, for all of York region, there was an additional $1.1 million that was to be delivered for the integrated homemaker service.

Of course, this expands directly from the question that has been raised here about long-term care. I think the commitment being made by the government is going to actually change the way that long-term care has been delivered in the past, and perhaps you might be able to explain to the people viewing here today how this commitment of dollars is going to actually change the way we deliver care to some of the seniors of the province.

Hon Mrs Grier: It's going to change the way we deliver care, but I think more importantly for consumers of care and their families, it's going to change the way in which you find out what care's available to you. Because one of the greatest frustrations for people needing long-term care and for the people helping them find long-term care has been, how do you know what's available? What's in my community? Where might there be a vacant bed if I'm looking for a nursing home or an institution, and can I get, if it's only Meals on Wheels, the kind of nursing care that I need to enable my elderly relative to stay at home, or myself, if I've got to the point of needing that?

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I think the biggest change that people will notice when we have completed the reform of long-term care is one-stop shopping. There will be a multiservice agency, which is the description that has been given to a non-profit community-based agency run by a board of volunteers from a particular community, which has a phone number that I'm sure will be made readily public to everybody in that community.

It will do an assessment of you when you need care, will assess once as opposed to now when you might see five different agencies, all of whom do an assessment to see if you fit their particular model and service they offer, an assessment which will identify what help you particularly need and which will then assign the coordination of that help to a placement coordinator who works within that multiservice agency.

That coordinator will have the responsibility for taking the assessment of what you need and matching that with the appropriate people to meet those needs. As I say, it may start from a very simple help with housekeeping or shopping and move on to quite intensive nursing or placement in an appropriate institution. I think that will be the first major change.

The second will come as a result of the expansion of the integrated homemaker all across the province. I recognize that in constituencies such as yours that cross municipal lines, as we plan and as the district health councils plan for the delivery of these services, we have to deal with those anomalies. But essentially, up to now you've only been eligible for homemaking if you were also getting some nursing or some physiotherapy. Under the integrated homemaker program, you can get that homemaker if that's all you need.

The expansion of the integrated homemaker will enable more people to get that service, and that's the program where the bulk of the funding is going and where I've been able to announce funding this year, and where, as we talk about expenditure control, we see a prime example of reallocation within that $17-billion budget from perhaps some who've had the bulk of the funding in the past -- the doctors -- to those agencies that haven't had sufficient funding in the past -- the homemakers and the home nursing component.

We will have both the locally based agencies, based on plans drawn up by district health councils and their long-term care committees, we will have the one-access and the placement coordination and we will have a more even provision of services across the province along that entire spectrum from home support to institutional care. This is something that, as a volunteer in the service agencies, I certainly expressed for the last 10 years the need for this kind of a coordinated, integrated approach.

We have moved as quickly as we could since becoming government to in fact finally put it in place all across the province, recognizing that how the program works and how it's delivered will vary from area to area. That's why the actual planning for both the number of multiservice area agencies and the number of services they provide and the geographic areas they cover is being done not with a cookie-cutter approach by the ministry saying what's good for the region of York is necessarily good for Thunder Bay or for Atikokan, but based on the planning that is being done with community consultation by the long-term care committees of the district health councils.

Ms Christel Haeck (St Catharines-Brock): Two questions, one which might be easier to answer than the other. On page 21 of the briefing book, Mr Wessenger and I came across a point which we felt we just had to ask, therefore I'm going to ask it. What it says is, "In addition, administrative support is provided to the Ontario Criminal Code Review Board, which operates under the authority of the Criminal Code of Canada." I'm wondering as to why.

Hon Mrs Grier: Mr Sharpe, fortunately, is still here. I'm sure can answer that question.

Mr Sharpe: Sorry, what was the question?

Ms Haeck: In the briefing book, it relates to the fact that the Ministry of Health is giving some administrative support to the Ontario Criminal Code Review Board relating to something under the authority of the Criminal Code of Canada, and I'm wondering why.

Mr Sharpe: That board used to be known as the Lieutenant Governor's Board of Review up until a year ago February.

Ms Haeck: Which says nothing more to me.

Mr Sharpe: It actually originated under the Mental Health Act many years ago and then was put under the Criminal Code. It deals with people who are found, it used to be, not guilty by reason of mental disorder, insanity and so on or unfit to stand trial, who have committed violent acts, end up in places like Penetang and St Thomas Psychiatric and so on.

The board historically, as I say, was under the Mental Health Act and was therefore supported as a Ministry of Health tribunal. In its evolution through various stages with the new mental disorder amendments to the Criminal Code about a year and a half ago, it became the Criminal Code Review Board. It used to be advisory to cabinet and the Lieutenant Governor, and now it makes decisions autonomously of cabinet, but the actual administration of the board has been left with the Ministry of Health.

The ministry, a dozen years ago, set up a support system: administrative staff, rented premises and so on. It had historically been chaired by a judge; it's not chaired that way now. The expenditures referred to would simply be related to those types of ongoing support requirements by the ministry. But it does function as an independent tribunal. The numbers you have there are primarily secretarial and admin staff supports and payment for members of the board and so on.

The Chair: Seeing that it is 6 of the clock, this committee stands adjourned to reconvene tomorrow, Wednesday, July 28, in room 151, where we have approximately five or better hours remaining to complete the estimates of the Ministry of Health.

The committee adjourned at 1757.