Assemblée législative de l'Ontario

MINISTRY OF HEALTH

CONTENTS

Tuesday 14 June 1994

Ministry of Health

Hon Ruth Grier, minister

Margaret Mottershead, deputy minister

Dr Les Levin, cancer coordinator, strategic priorities resource group

Mary Catherine Lindberg, assistant deputy minister, health insurance and related programs

Jodey Porter, assistant deputy minister, health strategies group

Mark Rochon, assistant deputy minister, institutional health group

STANDING COMMITTEE ON ESTIMATES

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

*Vice-Chair / Vice-Président: Arnott, Ted (Wellington PC)

Abel, Donald (Wentworth North/-Nord ND)

Carr, Gary (Oakville South/-Sud PC)

*Duignan, Noel (Halton North/-Nord ND)

Elston, Murray J. (Bruce L)

*Fletcher, Derek (Guelph ND)

Hayes, Pat (Essex-Kent 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:

O'Connor, Larry (Durham-York ND) for Mr Abel

Sullivan, Barbara (Halton Centre L) for Mr Ramsay

Wessenger, Paul (Simcoe Centre ND) for Mr Hayes

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

Also taking part / Autres participants et participantes:

Dr Robert McMurtry, dean of medicine, University of Western Ontario

Clerk / Greffière: Grannum, Tonia

Staff / Personnel: Israel, Edward, research officer, Legislative

Research Service

The committee met at 1558 in committee room 2.

MINISTRY OF HEALTH

The Chair (Mr Cameron Jackson): We have reconvened to continue with the estimates of the Ministry of Health. We have six hours, three minutes remaining.

I welcome the minister and the critics. When we left off, Ms Sullivan had the floor. Before I recognize the third-party critic, does the minister has any written responses or any short responses to any of the questions that were tabled?

Hon Ruth Grier (Minister of Health): No, not at this point, Mr Chair.

The Chair: Fine. If that's the case, Mr Wilson, it's a 20-minute allocation.

Mr Jim Wilson (Simcoe West): Oh, 20 minutes?

The Chair: What would you like? Do you want to do a half-hour segment?

Mr Jim Wilson: I wouldn't mind.

The Chair: Done. Get going.

Mr Jim Wilson: Thank you, Mr Chairman. Minister, perhaps you could bring us up to date on the 1993 OMA-government agreement. In reading some of the medical journals and the OMA journal, it seems to me that when it comes to a number of things the government committed to in this agreement, the government has been a little lax in living up to some of the conditions set therein. I don't know if you need any staff to help go through this.

One of the issues, of course, that has hit the media recently is incorporation. The mention in the agreement is that the government would move to introduce legislation to allow physicians to incorporate in this province. It's a bit disturbing, and I see you've had to do a bit of damage control when the Star last week made it known that the government had done a secret report for your eyes only with respect to the cost and some of the legal questions concerning the incorporation of physicians.

I was just wondering if you want to take this opportunity to bring us up to date on what is happening, what that report indicates to you and why the government hasn't moved to introduce legislation thus far.

Hon Mrs Grier: I'd be very glad to take some time to update the committee on the status of the agreement. It was a very far-reaching agreement. As members will recall, we had the framework agreement signed with the OMA in 1991. Then there was the expenditure reduction exercise that our government embarked upon, which talked about the discounting of physicians who set up practice in the areas where there was an oversupply of physicians.

We hoped to address the distribution of physicians by encouraging them to settle in those areas or domains where we lacked physicians. There was very strong reaction in opposition to that proposal. In fact, I think my critics might have contributed to some of the debate around that issue.

Mr Jim Wilson: We were certainly very helpful on that.

Hon Mrs Grier: When we entered into negotiations with the OMA with respect to the social contract, we had on the table the update of the framework agreement of 1991, the expenditure control measures that had been taken, as well as the need to curtail the growth in expenditures on the salaries of public servants, of those paid from the public treasury, which of course included physicians and other professionals.

The negotiations were very far-reaching and a number of significant agreements were reached. Let me just quickly go through them and then focus on the one that I know has been of interest today. One of the agreements was with respect to third-party services, something which has not been covered by OHIP for some time but on which there seemed to be a lack of clarity as to whether they would be paid for by the person seeking the certificate of good health for employment or summer camp or whatever or the person requiring that such a certificate be produced. Our agreement was that in fact the responsibility lay with the person requiring the third-party services.

We have done a fair amount of work internally around that. First of all, there was Bill 50, which gave us the statutory authority for doing that and which, as you know, received royal assent on December 14, 1993. There have been internal discussions to look at which regulations within ministries require health examinations and therefore doctors' examinations, which might be obsolete or we might no longer need or do it another way. That has been ongoing.

Then there was discussion with the OMA to identify what statutory obligations could be eliminated, but also the way in which we could write a regulation that would enable us to require the third party to pay and for the OMA to revise its guide to billing for uninsured services. That has taken a fair amount of time, but a great deal of work has been done and we are well on the way to completing the requirements of that portion of the agreement.

Another significant element in the agreement was the requirement to bring in a new health card. I know again both my critics and the Ontario Medical Association believed we had not moved as quickly as we had hoped to on that initially. I took the position that it was important to get it right. Again we did an enormous amount of research and preparation for implementing a new card and I was able to announce on May 3 that we will be having a new photo health card. We are now moving to implement that, so that part of the agreement has been lived up to.

Distribution measures: As I reminded you, one of the early initiatives was the attempt to deal with the distribution of physicians by discounting, so finding an alternative to that was very key to the negotiations from our point of view. We negotiated that one of the ways in which that would be done would be direct contracts in traditionally hard-to-service areas. Again, we have had long discussions with the OMA as to the terms and the wording of those contracts. I think we both acknowledge that that has been ongoing.

The deadline that was in the agreement was October 31, 1993, but again discussions have been ongoing and I would hope that the OMA would acknowledge, as I do, that we set time lines in the agreement without perhaps either party understanding the complexity of the issues and the amount of work that needed to be done in order to in fact make them a reality.

Continuing medical education was another element and that was funds to be transferred to the OMA. That has been done, and the OMA has made a proposal as to how to continue that education program. That is under review by the ministry.

There was an agreement with respect to locums and, again, the funds were transferred by the ministry to the OMA and the OMA is now proceeding with implementation of that.

The public education was very much a part of it and our extremely successful program in London, Ontario -- a town I just came from and nobody has colds there today, it's very warm -- was an education and health promotion initiative that, the committee I know will be interested to know, recently won a prize for the advertising of that campaign as well. So that has been completed.

There was to be a task force on the funding and looking at the future of medical care. That has been established and is up and running.

There were to be some changes to the schedule of benefits with respect to delisting and that has been implemented. You will recall the work of the committee that was set up to hear the public and to make recommendations. Again, we accepted their recommendations, so that has been in place.

There were some other schedule changes that have been made or that are under discussion between the ministry and the OMA but, by and large, we are well on the way to implementation of significant portions of that agreement.

The question, of course, was raised around incorporation, and I'm sure the member will recall that there was agreement in principle in schedule 9 of the agreement to the incorporation of physicians with a reference to the Health Professions Regulatory Advisory Committee with respect to how that might be accomplished. The press is aware, as I gather the world is now aware, that I have received the report from PRAC and that is being reviewed. That just occurred on May 30, which was the deadline that they had set to respond to us, so we are again on time on that.

We have their report, and I'm reviewing it. It is in the process, I think, of being translated into French, which we hope to have completed tomorrow, and as soon as that has been completed, it will be transmitted to the Ontario Medical Association. I'm not really at this point in a position to comment, nor do I think I ought to, until the OMA has had an opportunity to review the recommendations.

Mr Jim Wilson: Thank you, Minister. I just want to go back to a couple of things that you've said. One is with respect to on-call emergency services and physician distribution measures. Let's take on-call emergency services first. You still have a problem in Red Lake. I gather the hospital there has bought a bit of time through an agreement directly with the physicians, as we're seeing this happening in other areas of the province.

What is the ministry's plan to come to terms with this issue with respect to on-call emergency services, particularly in rural Ontario? Unless you can take some leadership and get a handle on this, the problem seems to be spreading. The tripartite approach doesn't appear to be working at this point.

Hon Mrs Grier: Mr Chairman, I'm not prepared to agree with the member that the tripartite approach can't work. I acknowledge that it hasn't at this point, because it's only tripartite if there are three people at the table. As I've said many times, I sincerely regretted that the OMA, having begun discussions with us and the Ontario Hospital Association last November, then decided in May that they would not continue any more. I am delighted that they are now prepared to come back and be part of those discussions.

We are at this point discussing with them and with the OHA the terms of reference of reconstituting that committee. The OHA has asked us if we can come to a conclusion by July 31. That would certainly be my wish, and I continue to hope that, with goodwill on all sides, that could happen.

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In the last couple of days, last Friday I was down in southwestern Ontario and had the opportunity to talk at first hand with hospital administrators wrestling with this problem. I don't think I would agree with you that it's spreading, but I certainly acknowledge that it has been a very long-standing problem. It hasn't just suddenly started. There have been small hospitals topping up the salaries of physicians for quite some time. Just as we are rebeginning the tripartite discussions at the provincial level, so are we working with individual hospitals to try to resolve their problems on an individual basis, and I think it's appropriate to continue on both tracks.

I was encouraged this afternoon when I was in London meeting with the Thames Valley DHC to hear from representatives in the Middlesex area that the arrangements they had worked out with the community, with the physicians and with the hospital for the four-county hospitals, while less emergency service than they had previously had, in fact seemed to be satisfactory and that they were watching hopefully as to how it would evolve and whether that would set a pattern that would enable them to deal with the problem in the long run.

In other areas there is enormous frustration, because despite attempts to work out agreements with physicians and an enormous amount of goodwill on the part of the hospital administrators, and certainly a willingness by the ministry to sit down and discuss an alternative way of paying the physicians so it is worth their while to cover emergency rooms, it takes two to tango. In some cases, the physicians have not been willing to come to some agreements. But it is, to me, a very major problem, and we have to find a way of resolving it.

Mr Jim Wilson: Could I ask you, though, what the ministry's position is in these discussions with the OMA? Specifically, is there any budging on your part at all on going outside the $3.85-billion OHIP pool, and secondly, what are you offering? What do the direct contracts look like for looking after physician supply in underserviced areas and with respect to on-call emergency services? What are you offering to these talks?

I just spoke to a large group of physicians in Owen Sound last night, and no one out there is clear what the ministry's position is going into these talks -- well, not going into them, but the talks that have been ongoing off and on over the past few months. Can you tell us what your bottom lines are and what you're looking for?

Hon Mrs Grier: Let me be very clear, because I'm sorry, I thought I had. First of all, I think it's important to understand that the direct contracts that I mentioned as part of the OMA agreement are not designed to resolve this issue particularly. They are more to deal with supply in the areas where it has been particularly difficult to get physicians. The on-call emergency is a debate about money. The other is as much a debate as to how do you persuade a physician to set up practice in an area like Armstrong, which I guess is one that hasn't had a regular physician or has had a locum on a renewal for quite some time.

Mr Jim Wilson: But, Minister, they're very much tied. There's a husband and wife, two physicians, who have a practice for sale in Alliston, and one of the reasons they can't get anyone to come to Alliston, the same as I was told in Owen Sound last night, is because of the emergency coverage also. So the two are very much tied if you're a physician looking to go into an area in rural Ontario.

Hon Mrs Grier: The contracts that we've been certainly discussing with the OMA are not going to solve the Owen Sound-southwestern Ontario problem. Yes, I have to work within the $3.85 billion that was negotiated with the OMA, which is the amount we have budgeted for OHIP services in this fiscal year.

If it is to be topped up, as physicians are asking, then it comes from hospital budgets, and that's precisely what the small hospitals have been doing and what we don't want them to continue to do, or it comes from somewhere else within the estimates that you have. I'd be happy to have whatever comment the committee felt it wishes to make as to areas in our budget where it would see us moving some funding from one particular vote to another.

But as far as I'm concerned, our budget is $3.85 billion for 22,000 physicians in this province. What we have to do is, within that, look at the equity issues and look at how in fact people are paid. That can be done almost unilaterally by the OMA with respect to the schedule of benefits, which rural physicians have asked for many times within their own organization and of their own bargaining unit. Failing that, the ministry's position is that there can be conversion from the fee-for-service pool of $3.85 billion to another way of paying physicians.

That has to be not just for emergency room service, in other words, not billing fee-for-service between 9 and 5 and then having a salary on top of that, but looking at how much is in the pool, whether it is, as we said in Red Lake, related to the actual billings of those five physicians or whether we can agree on what the pool ought to be and converting that amount of money into an alternative payment plan. That has been our consistent position in all of these discussions, and the amounts and the mechanisms are what are on the table.

Mr Jim Wilson: Just with respect to an alternative payment plan, though, it's very difficult to figure out what model you're pursuing. Do you have an ideal one in your mind? Because certainly, in talking to physicians, many of them think it may very well be from 9 to 5 that they're on fee-for-service and then they get an on-call hourly rate or something like that. So do you want to just comment on what the alternative payment plan is? Is it like what we have in Hamilton, where physicians serve in the emergency room? Of course, that's just ER specialists, I guess.

Hon Mrs Grier: There are a number of models and variations on models. Perhaps I could ask the deputy to comment on that aspect of things.

Mr Jim Wilson: After all these months, I'm assuming you've got this narrowed down and have an objective in these talks.

Hon Mrs Grier: Let me be clear: We're open to proposals, creative ideas. We are genuinely negotiating what suits the needs of particular physicians and what meets the demands of their lifestyle, practice, locality and the needs of the hospital. So if there are variations of models, we don't have any predetermined cookie cutter to impose. But let me ask the deputy to comment.

Mrs Margaret Mottershead: The discussions that we have been pursuing in Red Lake, as an example, involve an alternative payment plan that would establish a consistent and secure level of remuneration for physicians, in return getting an obligation to provide the full range of community services that they would normally provide through the fee-for-service system, as well as the on-call, and to be available for emergency room coverage. We're wanting to have a plan that is more comprehensive in terms of allowing the stability of income as well as the return for service. That's the kind of model that we have been discussing with Red Lake and with other physician alternative payment arrangements.

There are out there, at a minimum, about 22 different alternative payment arrangements. They vary and they all reflect the circumstances that were prevalent at the time that the discussions and negotiations took place, and today you may not want to necessarily replicate those particular arrangements. We're trying to be as comprehensive as possible in our discussions so that we have at the forefront the patient and public interest as the first consideration or objective, to make sure that there is comprehensive coverage.

Hon Mrs Grier: Perhaps you should bring him up to date on Red Lake too, before we get into another question, because you're more close to that than I am.

Mrs Mottershead: There were meetings with Red Lake last week. The OMA, the Ministry of Health, the Red Lake hospital as well as the Red Lake physicians met and it was a very positive discussion in terms of a solution. Both Ear Falls and Red Lake have determined that within their geography there should be a total of seven physicians, Ear Falls having one physician dedicated to it and Red Lake agreeing to having six.

What remains as part of the discussion is a specific request that was made by the OMA and by the hospital physicians to have a bilateral discussion with the hospital without the ministry present so that they could explore other issues outside, over and above the on-call emergency room. They wanted to deal with procedures, relationships with respect to other hospital services, and we've allowed that to happen. That discussion with the hospital is going on, and we hope to get back next week to serious discussions. We're hopeful we can get an agreement done.

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Hon Mrs Grier: In the meantime, physicians are resuming their on-call emergency coverage.

Mr Jim Wilson: Turning to recruitment and retention initiatives, Minister, you covered that briefly. One of the things you mentioned was that the bulk of money had already been given to the OMA. Can you expand on that? I assume that was part of the money that was used to fill in at Red Lake when the locums were required, but it's one part of the agreement that I was never clear on. You handed the money over to the OMA to cover locums where gaps exists in service?

Hon Mrs Grier: No, it was in addition to what the ministry was continuing to do. But let me ask the deputy to address that.

Mrs Mottershead: What we decided to do is in two pieces in the agreement. It deals with the OMA and the locums. The OMA had requested the transfer of funds so that it could deal with the short-term, very temporary replacement and relief provided by locums. It's that part of the program that was transferred to them. The locum program that deals with providing longer-term relief in underserviced area programs still remains part of the ministry's underserviced area. They deal with the very short term, one or two days to cover off for continued medical education or very short-term sick leave.

Mr Jim Wilson: Was that money in addition to the pool?

Mrs Mottershead: Yes.

Mr Jim Wilson: With respect to recruitment and retention, are you making any progress? As I said, as you travel throughout the province there still seem to be a great many problems out there with respect to people not wanting to come to rural parts of the province. To be fair, you need the wisdom of Job, I think, to solve this thing, but you've had quite a few months to work with it.

Hon Mrs Grier: I had wondered, Mr Chair, whether having somebody from --

Mrs Mottershead: PCCCAR.

Hon Mrs Grier: PCCCAR. You say what it stands for. I always get the Cs confused. Anyway, it's a committee headed by Dr John Evans which has been looking at recruitment and human resources. They have been working extensively and have a number of subcommittees and groups working on it as a long-term issue.

We have the immediate problems in those communities that haven't got doctors, but I think they reveal some fundamental flaws in the fact that there has been no human resource planning throughout the system in the past. How can we do it and do it in a way that meets the needs of Ontario? Because this is happening nationally. I'd be more than happy to have somebody here who could speak to that in some detail.

Otherwise, we can give you sort of a rundown of what the committee has been doing and where the work is at. It is tied to both education and how you make sure that you are training people in the right specialties and how you make sure that you are training people so that they are more comfortable operating in isolation, if that's what's going to happen in rural areas, and how you make sure that they are encouraged to locate outside of the urban areas by having part of their training in northern Ontario or rural Ontario. It has been the academic health science centres that have taken the lead in looking at the entire system to see how we can start way back as soon as they enter medical school in order to have some long-term solutions.

Mr Jim Wilson: Along that line, Minister, you know that five weeks back representatives from the Collingwood General and Marine Hospital, in particular Dr Peter Wells and Mr Maurice Lacerte, and I met with Jodey Porter. I think in my opening remarks I did mention that I would be asking about the status of the ministry's response to the family practice residency program that's being proposed to be run out of Collingwood General and Marine Hospital. Has the ministry got a response to that?

Hon Mrs Grier: I don't think we have an official one. My deputy tells me we have referred that proposal to the Evans committee for review. That may be a valuable issue to be addressed if Dr Evans or Dean McMurtry, who's part of that, might be available to come in at one of the other sessions.

Mr Jim Wilson: Actually, that would be a good idea to deal with this whole issue. I would certainly take you up on that offer, if you want to arrange that.

Hon Mrs Grier: We'd also I think talked about somebody from the Institute for Clinical Evaluative Sciences coming in. Has that been scheduled? For tomorrow? Okay.

Mr Jim Wilson: That would be quite interesting too.

Not to belabour the point, but just back to on-call emergency services, the OHA had asked that you try and come to a resolution on this matter by the end of July. Do you have a timetable in mind at this point?

Hon Mrs Grier: I would certainly love to hit that target. Again, I have indicated to ministry officials that we will put whatever time is required into making sure that happens, but it means resolving with the other two parties the precise terms of reference of the committee, what we're talking about, again, to the table. I don't know where we are from scheduling the first meeting.

Mrs Mottershead: I have sent out a letter to the OHA and the OMA inviting them to a first meeting and also to have a very frank policy discussion before we continue to schedule any further meetings. I don't know whether you've had an opportunity to read Hansard from the last session, but the minister did indicate that at least one of the parties had already established a precondition to the discussions when in fact they said they were coming into the discussion with no precondition. So we want to make sure there is a solid understanding that everyone is genuinely committed to having a resolution and the framework for that before we get too far down the line.

Mr Jim Wilson: Minister, I also mentioned in my opening remarks our disappointment to a certain extent with your decision surrounding the introduction of new health cards. Although I think the photo ID is on track, again I'd ask you the question, why continue with the magnetic strip and why didn't the ministry go all the way with smart card technology, which I understand was offered to you by the private sector?

Hon Mrs Grier: Certainly, as I think I said in my response to your opening comments, we think technology is changing very rapidly, and one of the reasons I was anxious to see a renewal cycle for the card is that it enables us to take advantage of technology as it changes. At this point the initiative was designed to deal with fraud and to make sure we had an adequate registration database that had everybody in the province who was entitled to a health card.

The other difficulty is that all the points of the provision of services are not yet equipped with the technology that would enable them to get the best use from a smart card. We are moving to put in place the technology that enables them to deal with a swipe, but we haven't even got to that point yet.

We really are starting from scratch. There wasn't even a division within the ministry looking at these things three years ago, so to in fact put in place both the mechanisms within the ministry and then within hospitals and doctors' offices is a major first step. I know you would feel we should move all the way to a smart card, but if we're not in a position to take advantage of that at all the points of provision, it seems to me that we do the first step first and are ready in five years, if necessary, to move to a more-advanced technology.

Mr Jim Wilson: Just a couple of points on that. You're aware that Management Board since 1986 has had sort of a government smart card project up and going. I know it hasn't been enthusiastically received over the years by the Ministry of Health, but to say that it has only been in the last couple of years this has been looked at by the government is just not true at all. In fact, I have people on my own health advisory --

Hon Mrs Grier: I was referring to within the Ministry of Health and the registration base in the investigation elements within our ministry.

Mr Jim Wilson: The second thing is just a very direct question. I'm told by some of the major banks that joined the banks together to form a consortium that they had offered to pay for much of the upfront costs of a smart card technology system, that they were going to pay for the hardware, both on the government side and in physicians' offices.

Yet, first of all, they had a very difficult time making the case to the government, and then they did get in at the ADM level and the deputy level, I think, and finally they're at a loss. I talked to someone as late as last Wednesday, a week ago tomorrow, about this, and they're at a complete loss as to why the government didn't take them up on their offer. Do you want to fill us in on why?

Hon Mrs Grier: There have been extensive discussions with the private sector about the technology. We'll soon be taking advantage of a lot of their expertise. I don't know whether the deputy or the assistant deputy minister wants to respond to the specifics on that.

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Mrs Mottershead: Mary Catherine Lindberg is the assistant deputy minister for health insurance and related programs, and she may be in a position to amplify. To my knowledge, there have been, as you say, a number of discussions with a group that was established as a technical advisory group -- and it was ad hoc, off and on -- advising the ministry on health card issues.

Certain proposals were being discussed, but we never received, to my knowledge, a proposal from any financial institution that actually set out exactly what they're prepared to do and what the return would be to them or others on that particular venture. There were some discussions with them, but no one actually came forward with a specific and firm proposal.

The other element I'd like to add -- because you did raise the issue of smart cards and the fact that it has been discussed in government for at least 10 years, and I would acknowledge that -- to the issue with the smart card is the fact that you would require a major overhaul in the technology infrastructure of government.

We're not talking about $1 million or $100 million; we're talking billions of dollars to deal with that particular catch-up in technology. Therefore, although it's a very tempting idea to pursue, it's just not economical in the very short term, given that other players who would have to be involved and hooked up to this technology wouldn't even have the wherewithal to come up with that kind of investment.

Mr Jim Wilson: Can I just make one quick point, Mr Chair? I know you're going to cut me off. I appreciate the deputy's response, but I can tell you very clearly that the private sector and the banking consortium has a very different view of what these discussions have entailed, and that is that they weren't given the access to make their case, that of course they never got to the formal proposal stage because they found all the way along that your government wasn't particularly interested in what they were offering. Now whether it was based on cost or some other reason, that's unclear to them at this point and it's certainly unclear to us.

I'm well aware that an overhaul of government computers is required. I think that the Ministry of Health, though, if you're going to do proper management of the health care system in the future, is going to need good data management and analysis. You're not going to have it with the magnetic strip system, and David Naylor isn't going to live long enough to look at every treatment in the province.

Hon Mrs Grier: I'd like to respond, Mr Chair.

The Chair: The whole process is a response, but he did say it was a final comment, and you're now into the next cycle here.

Mr Derek Fletcher (Guelph): You can finish your comments with us.

The Chair: Well, people can do that any time, but at some point you cut it off. I'm afraid I served notice that I was cutting it off, and if you want to raise a question about smart cards, Mr O'Connor, I'll recognize you.

Mr Larry O'Connor (Durham-York): I appreciate the opportunity to comment, and perhaps follow right in here now, because the public accounts committee did take a look at the health cards. We looked at it in depth. When we had the people from the banks come to the public accounts committee and say, "Okay, give us your best shot, what you think about health cards and the technology that's available to date," the banks even told us themselves, "We don't use the smart card ourselves." There was one bank that acknowledged that they use it for some internal security, and that was it. I mean, the banks don't even use it themselves.

The reason they're not using it is because they go through a process right now through renewal cycles, and that keeps their system with the integrity that's necessary for what they have. So I don't know, but it's not quite what I heard in the public accounts committee, and my critics were both there for that set of hearings.

Minister, if I could get you to comment first off on the OHIP and refugee decision that was made today by the federal government. I think that's an important move that's happened. I know that you were quite adamant about your stand on what the Ontario taxpayers should and shouldn't be paying, and I'd like to offer you the opportunity to comment on what had happened as far as the announcement by Ottawa today.

The Chair: And what effect it will have on the estimates.

Hon Mrs Grier: I think it was built into the estimates, let me say to you, and let me say how delighted I am that in fact the federal government has responded positively to our request that they cover the health costs of refugees. Ontario was one of the few provinces where this in fact was not the case, so we requested the federal Minister of Citizenship and Immigration to accept responsibility for the health care costs of refugee claimants, as they did in other provinces.

As I say, I'm delighted that they have agreed to do that. We are in negotiations with them with respect to the timing and the specifics of how this will work and we anticipate that this will take some time. In the meantime, as I made clear at the time of my announcement, refugee claimants will remain covered by the province, so this is not a case of anybody losing their coverage while waiting for it.

The estimates of the medical bills of the approximately 70,000 refugee claimants who are registered, or were as of January 1994, for OHIP coverage, were estimated to be $32.5 million annually. So we have anticipated savings of approximately that amount built into our total savings of $48 million for eligibility.

How much of the refugee claimants savings we will make this year we're still not clear on. It depends how the negotiations go and on the timing. But I welcome the federal government's response and look forward to working constructively with them to resolve a problem that I think has been for too long shouldered by the province, where it was clearly the responsibility of the federal government.

Mr O'Connor: The next question I want to place is on the cancer strategy. I know the document was put out there for the people of Ontario. The strategy is evolving. I wondered if you could give an update or maybe if you have someone here that might be able to help you with that. I'd like to know when people are going to be able to see the full impact of the strategy taking place. I was pleased to be part of the tobacco end of that strategy. I understand that there's a task force that is part of this strategy as well, and I'd just like to ask when we will feel the impact of that strategy.

Hon Mrs Grier: I guess the answer is over time. Perhaps I can ask Dr Levin to add and to bring the committee up to date on what has happened since my announcement in April.

The release of a cancer strategy for the province for the first time was extremely well received, very warmly welcomed by both the providers of service, the cancer institutions and treatment centres, as well as the support groups and the Cancer Survivors Network, who welcomed the fact that we were looking at a continuum of care.

In terms of when we see it actually in place, our expansion of radiation treatment is now unfolding and that is happening at some of the centres. I in fact added an additional $15 million in new funding as part of my announcement in April. That will enhance our ability to do bone marrow transplants and cut down on those waiting lists, and I think we'll begin to see that quite shortly.

When it comes to looking at planning for the future, we are still reviewing where the next expansions ought to occur in terms of doing that planning. The change in the way the planning is happening is what the cancer network and the regional networks are all about.

Dr Les Levin, who is our cancer coordinator, is here, if I could perhaps ask him to come forward and give some of the details. I know that the interest in cancer treatment is enormous and that people will be glad to hear that. If you could just introduce yourself by name.

The Chair: No, Minister, you already have, and I was going to thank you for having done that. So please proceed, Dr Levin.

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Dr Les Levin: As the minister mentioned, Life to Gain: A Cancer Strategy for Ontario was announced in April. The strategy looks towards a provincial framework which is brought together by a Provincial Cancer Network to be implemented regionally through a series of regional cancer networks.

The Provincial Cancer Network has met twice. There are seven new initiatives and five pre-existing initiatives which come out of the cancer strategy. The seven new initiatives have required the development of seven working groups with regional representation.

Each of the working groups has now met, had their first meeting. They have been given a time line to present implementation plans for their respective areas by November 15. We are at this point encouraged by the time line. If they're keeping to their time line, we hope to have an implementation plan submitted to the deputy for the formal implementation of the cancer strategy by January 1995. The implementation process should begin shortly thereafter.

Hon Mrs Grier: Perhaps I can ask, Dr Levin, about the recent announcement about Princess Margaret and Toronto Hospital, their working together. Could you comment on that and how it fits in and what you think the impact of that may be?

Dr Levin: A steering committee has been struck to look at the coordination of oncology services between the Princess Margaret Hospital and the Toronto Hospital. I understand at this point that exercise may be extended beyond Toronto Hospital and may incorporate Mount Sinai and maybe Women's College and St Mike's. That effort, I heard, began three months ago.

The provincial cancer strategy is mentioned, in the press release announced last Friday, as being one of the driving forces behind that merger. It's not really a merger; it's just one oncology program which is headed by Dr Simon Sutcliffe, but certainly consistent with the cancer strategy. It's something which was warmly applauded by the Provincial Cancer Network, and we hope to see more of that kind of activity taking place in terms of striking partnerships across the province.

There has been an informal announcement that Essex will merge its cancer planning activities with the rest of southwestern Ontario. Until now it's been isolated from that point of view, and there are attempts to try and get the Kingston and the Ottawa regional cancer centres to merge their planning activities within one region, so there's a lot of movement taking place in terms of striking those partnerships. We'd like to think that the cancer strategy had something to do with that.

Hon Mrs Grier: Thank you very much.

Mr O'Connor: I guess this would be a political question, so I'll point it to the minister and perhaps he can answer it. I know that my Durham colleagues would want me to ask the question about Oshawa, and perhaps I'm out of line by asking that question.

I'm not looking for an announcement, but I know that there's a lot of pressure from Oshawa General Hospital for a cancer centre to come to that side of Toronto and get out of Toronto. I think that my Durham colleagues would probably be mad at me if I didn't place that question, so I'll place the question before you, Minister.

Hon Mrs Grier: Let me say that I certainly understand the pressure that there is on the eastern side of Metro for additional services. That certainly has been something that the Ontario Cancer Treatment Research Foundation has identified.

Part of the network is, how do we plan for the best location for the expansion of services? I think that we have to plan, in all of our initiatives with respect to health care planning, in a way that meets the needs of the most people as opposed to planning, in sometimes the way it was in the past, by pressure to make a decision and respond to the needs of a particular institution.

I hasten to add that nobody should read into that comment that perhaps Oshawa might not be the most appropriate place to expand. What I'm really saying is that in reviewing the capital plans of OCTRF and the needs of the eastern side of the GTA, then we will certainly be talking to all of the players and facilities in order to determine what the appropriate location might be. Will that satisfy your Durham colleagues? Is that vague enough?

Mr O'Connor: Thank you, Minister. That is about as vague as could be.

The Chair: Not prior to the next election, I can assure you of that. Mr Duignan.

Mr Noel Duignan (Halton North): I guess I could ask a question.

Mrs Barbara Sullivan (Halton Centre): On a point of order, Mr Chairman: I just wondered if, while Dr Levin is here, we could kind of break into this so that he doesn't have to come back three or four days. If we can just watch the clocks so that we all have even time, can Mr Wilson and I just have an opportunity to put a couple of questions?

The Chair: Mrs Sullivan, in 15 minutes you'll have an unfettered half-hour to cross-examine Dr Levin. Mr Duignan.

Mr Duignan: I guess I could ask some questions around local MSAs for the Halton region, but I'll avoid that question until another day.

The Chair: It's a matter for Georgetown, and that is in your riding, so feel free to raise it. I know I've been raising a concern about your riding.

Mr Duignan: That's true.

The Chair: Feel free to do it.

Hon Mrs Grier: Not as often as he has.

Mr Duignan: In particular, I just want to make reference again to the smart card technology that was raised by Mr Wilson. I too sat on the public accounts committee and in fact paid a visit to a company that handles that type of technology, the card technology for the banks. It was also quite strange that the banks themselves, even though they were promoting the use of smart technology, weren't too inclined to be using it themselves in their employee benefits.

This is what the card looks like with a chip in it. That chip holds 20 pages of information. I guess that hinges around the whole question of privacy, the right to privacy of an individual, what type of information you could put on that chip and who would have access to that information. So that became an issue.

Again around the new card, are we expanding the information on the strip? Are we strictly sticking to the same type of information that's on the present card?

Hon Mrs Grier: No. There will be, I think, expanded information and the capacity for expanded information. Perhaps I could ask Mary Catherine Lindberg to come forward and deal with some of those details. Thank you, Dr Levin.

The Chair: Welcome, Ms Lindberg. Could you just give us your title with the ministry.

Ms Mary Catherine Lindberg: Mary Catherine Lindberg, assistant deputy minister of health insurance and related programs.

The enhanced information on the new card will be an effective date and an expiry date. The birth date, gender, address and full name will be on there. That'll be visible on the card itself. There will also be a hologram to prevent fraudulent use or to be able to make new cards out of it. There will be a number of pieces of information on there that will give us more information, and it will be visible. Currently it's on the mag strip on the back of the card, but it's not visible. So these items will be visibly there.

Hon Mrs Grier: With respect to the magnetic strip, what information will be in the strip?

Ms Lindberg: The same information will be on the magnetic strip. Maybe I shouldn't jump in, but one of the things that makes magnetic strips look good versus smart cards in some ways is that you can start using it interactively with the state of the master computers. So you can swipe a card like you do your bank card and have interactive -- it will be on, the mag strip will contain that current information on there.

We also hope to be able to tie in there family members, so that if you have a child, the child then will be either tied to the mother or the father. Your child will be tied to your card, so we'll also know who the child is. Every time the child comes in to re-register, you don't have to bring one child one month and the next child the next month. Then when the mother or the father comes in to re-register, you'll be able to register all your children at the same time. That'll make a difference. So we will be doing some family ties on the new card.

Mr Duignan: One of the questions again -- in the public accounts committee we were looking at the whole aspect of fraud and how to tighten it up -- is the interaction between the SIN number and the health card number. You still don't have the SIN number on the health card?

Ms Lindberg: No, we don't.

Mr Duignan: Why not?

Ms Lindberg: We don't collect the social insurance number. We collect birth certificate numbers and correlate birth certificate numbers with the health insurance number. Then we protect the use of the health insurance number so that it can't be used for anything other than the purposes for which it is being collected. You can only use the health insurance number for use of health care; you can't use it to identify yourself for cashing a cheque, or you should not be required to produce that card to be able to do that.

Mr Duignan: The question is then asked, why can't we tie the SIN number in with the health number so we can verify in some cases who you actually are? We have the SIN number on your banking information and basically everything else in this province but we can't seem to tie it in with the health card number to verify who that individual is.

Ms Lindberg: There's a large concern from the privacy commissioner and the protection of privacy that we have one large database, that we tie everybody together so you can tie your SIN number, your bank number and your health card number, and some concerns about the use of what you would use that kind of number for. We have been looking at maybe it would be nice to have a large set database to do that kind of thing, but there are really concerns about infringement of privacy.

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Mr Duignan: That actually gets back to the smart card technology, where you would end up with a lot of that information on it so you would have a powerful amount of individual information on people.

Ms Lindberg: On each, yes, and if you had somebody who could read that technology --

Mr Duignan: With all sorts of access to that information. All you need is someone with the proper scanner to read it then.

Ms Lindberg: Yes, and they could read any kind of history -- your drug history, your lab history, your diagnostic history -- if you put it on a smart card.

Mr Duignan: Especially if it were with the banking consortium. Not only have they got your financial information now, but they would also have your medical information.

Ms Lindberg: That's true.

Hon Mrs Grier: As we talk about the card, it's important to focus on what's the purpose of the change, and essentially there are two ways of using the card. There's the protection of the system and the fraud issue, which was the one that was very much on our minds, and then there is the enhancement of our ability to track data and to provide a better quality of service.

The initial issue that we've been attempting to address is the quality of the registration data and the security of that data and the elimination of the suspicion or allegation of an enormous fraud and, therefore, a card that was secure and a card that had enough data in order to ensure that the person using it was the person entitled to use it has been our first priority.

I think, as we get more sophisticated in needing data and understanding how we can best use data in our health care planning, we may well enhance it. But to me the first priority and certainly the thing that I understood the Legislature and my critics in all of the parties were primarily concerned about was, "Assure us there is no fraud and no illegal health cards out there." To do that, the security of the card was critical, and I'm very satisfied that we're achieving that.

Mrs Sullivan: I guess if we can just go back to cancer for one or two minutes --

Hon Mrs Grier: I can ask Dr Levin to come forward, if you'd like to have some questions of him.

Mrs Sullivan: Yes. I'm interested, first, in knowing how the OCTRF strategy, which is available now, would be integrated into the Ontario strategy, their planning book that has recently been introduced, and where that will fit in your strategy as you move ahead.

My next question, I'd like to hear from Dr Levin how he sees the possibility of the network continuing into an agency aegis, and then I'd like to hear from the minister on the same thing.

Dr Levin: I really can't comment on the implementation of the OCTRF strategy because that's under their jurisdictional control. They are mandated through the Cancer Act to come forward with their own strategy and implement it according to their resource allocation. I think the timetable for implementing their strategy is really under their jurisdiction and I really am not able to comment on that. Having read their strategy, there are remarkable similarities in fact in the intent as put forward in their strategy and in Life to Gain. The same areas of concern appear in both strategies.

The Provincial Cancer Network is made up of a number of component representative parts, including the OCTRF, the OCI/PMH, the paediatric oncology group of Ontario. It recognizes community health care delivery systems. It goes beyond the OCTRF, and clearly OCTRF is a very important key player in cancer control in this province. The Provincial Cancer Network is working very closely with each of its key players to make sure that they are kept engaged in this process, and that includes OCTRF.

I don't see any real conflict between the overall strategic plans of OCTRF and I think it blends with the overall vision of the Provincial Cancer Network. The Provincial Cancer Network's vision goes beyond OCTRF, however, but recognizes OCTRF to be an important part of that overall vision.

Hon Mrs Grier: If I can add to that, I think as part of OCTRF's strategy -- it is less a strategy than a sort of capital plan and the expansions of what they see they need in the future. So the validation of that and the planning for implementation of that is something that the cancer network will be involved in as we decide how in fact to go forward in the outer years.

I think we know where some immediate pressures are, but as we look to the future, we would see the network as certainly being the way in which we had consultation and discussion from all stakeholders about OCTRF's plans, as well as, if the decision is made to expand treatment capacity at one place, then how do you build a support system and the linkages around that to make sure there is the seamless continuum of care that people need in that. Before you put Dr Levin on the spot, Mrs Sullivan, with respect to an agency, let me try and then he can answer after me. How's that?

Mrs Sullivan: I deliberately did it the other way.

Hon Mrs Grier: I know you did, and I deliberately avoided allowing Dr Levin to do that. I think that what we are putting in place as a network is in effect what is required to do appropriate planning to make it a continuation and to involve as many people as possible.

I think we have frankly too much work to do and too much need to involve the entire health system in the planning that we do to establish another major agency just looking at cancer, because it's very hard to know, when you're planning at the district health council level, where planning for cancer support systems ends and planning for long-term care and those kinds of supports begins. We have to integrate the provision of community-based services that meet the needs of the entire population.

Dr Levin: Do you want me to carry on?

Hon Mrs Grier: Be my guest.

Dr Levin: Just one other thing about the OCTRF strategic plan before I forget it: I really see the Provincial Cancer Network as providing the OCTRF with an important springboard to expedite the implementation of their strategic plan. As used appropriately, we always intended the PCN to capitalize the activities and to enhance the activities of all of its constituent members, and I think there are wonderful opportunities for that to happen.

The cancer agency, as the Provincial Cancer Network, will re-evaluate its own status in a process probably beginning by the end of the year to find out exactly what its future is and what the umbrella organization for this province might look like. It might be the Provincial Cancer Network, it might be a sibling of the Provincial Cancer Network or it might be something totally different.

The major objective of the Provincial Cancer Network is to come forward with a plan to implement the cancer strategy -- that's the immediate objective -- and to bring key players around the table so we can have people talking to each other about the very urgent needs in cancer care delivery in the province. It has a fairly short- to medium-term objective. What evolves from it is one of the exciting parts of the Provincial Cancer Network, because at this point we don't really know.

Mrs Sullivan: I suppose that one of my concerns, and I have expressed this from the very beginning, from the very day of the announcement, is that the network itself is time-lined and is temporary. I understand that it will be coming forward with recommendations with respect to the future, but it seems to me that the problem, for many, many years, in ensuring that there is an appropriate cancer control strategy is that there has not been a continuing body responsible for long-term planning, and therefore we have continuing cycles of crisis that are highly problematic. I saw once again the framework for another cycle of crisis and I think that's a problem and I think it should be looked at very seriously. I hope that the network will.

Hon Mrs Grier: That's precisely its objective.

Mrs Sullivan: That's all I have on cancer.

Hon Mrs Grier: Mr Chair, there was some discussion earlier about human resource planning and the committee PCCCAR. Somebody's got to know the anagram for PCCCAR.

Interjection.

Hon Mrs Grier: Jodey does. However, Bob McMurtry, the dean of the academic health science centre, happens to be on his way to the building and would be available to answer some of those questions within the next ten or 15 minutes, if that would be helpful to the committee members. I think they would find it interesting. He can tell you what PCCCAR stands for.

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Mrs Sullivan: The next area that I wanted to move into is the obligations of the ministry under pay equity programs. As we look at the latest pay equity legislation etc and I leaf through the estimates, I see pay equity obligations or allocations --

Hon Mrs Grier: Can you direct me to the page in the estimates?

Mrs Sullivan: Yes. There are a whole bunch of them: page 182, long-term care facilities, $8,742,500; public health, page 155, $1,015,200; community-based care, page 191, $15,922,400; page 83, hospitals, $29,891,900; and community mental health, $90,500.

My sense is that in fact what I have found here is not all of the obligations the ministry will face or all of the demand the ministry will face with respect to that pay equity legislation, depending on the proportional value results or comparative results, that in fact the demand is far more for pay equity adjustments than have been allocated.

I would be interested in knowing, perhaps not today but I would like to see some figures, first of all, on what the demands are that are coming from the broader public sector. Certainly in some cases, I understand that the demands are as high for change as $9 an hour, and if those demands, as I anticipate, substantially exceed the supply allocation, then how is the ministry going to deal with this issue?

We're talking about transfer agencies who are dependent on the Ministry of Health for funding: long-term care facilities, public health bodies, community-based care agencies, hospitals and so on. Many of the hospitals clearly have set aside reserves, certainly for the first two or three years of pay equity, but the new pay equity law may make a significant and different impact on what their calculations were.

I think that it would be useful -- not today, because I know that I'm coming at you out of the blue on this -- for us all to have a real understanding of what the ministry obligations are in this area, what the demand is and what the supply limits are.

Hon Mrs Grier: I'll ask the deputy to give a response.

Mrs Mottershead: We would be pleased to provide that information. However, I think I should flag that some of this information is retrospective rather than prospective, because when we do our pay equity survey, we actually have to be satisfied that there isn't just a pay equity plan but there in fact is a process of paying out to those individuals the pay equity portion that's entitled to them.

As you're well aware, in the legislation it requires that 1% be set aside for each employee, particularly related to job-to-job, and we find that most hospitals have been accruing the 1%, and in fact over the last few years, the government has provided at least a ratio of 75% to 80% against that 1% requirement. So there has been a tremendous amount, I would suggest, of relief, particularly to hospitals for the job-to-job.

There are three other elements that the government has entertained in legislation in addition to job-to-job, and that is proxy, proportional, and in fact one element which the government decided to contemplate late last year was related to down payment for those organizations that had difficulty coming up with their plans around proxy and proportional; therefore, not to put anyone at disadvantage in terms of the female population in certain establishments, the government decided to introduce a down payment program.

I can certainly provide that information and it may not be possible to do that for tomorrow because it requires a little bit of work, but certainly before the end of the session on estimates.

Mrs Sullivan: It seems to me that is going to emerge as a larger and larger issue in this field and we should know what's happening.

I want to go back to the emergency on-call, just for a very brief second. During the discussion with Mr Wilson, the minister indicated that in fact what was happening now was that the terms of reference for a meeting between the ministry, the Ontario Hospital Association and the OMA were being discussed. The second impression I had as the discussion was going on was that in fact the ministry contemplates the necessity for separate negotiations for each situation rather than one broad-band policy.

Certainly there was a reference made to some previous negotiations that you might not want copied -- I assume that Mount Forest would be a perfect example of that -- but am I correct in assuming that there will be one APP or other approach or that there might be individual approaches for each scenario, by example, that Red Lake would have to be considered in isolation from the situation in Clinton or in Hanover or wherever?

Hon Mrs Grier: Let me be clear about what I was saying, and I'll ask the deputy and she can feel free if I've misinterpreted, but certainly my hope had always been that we would have a provincial framework, and that was what the committee we established last November between the Ontario Hospital Association, the OMA and ourselves was designed to do, a provincial framework that would enable us to deal with small hospitals and with the conversion of funds from the $3.85-billion fee-for-service pool into alternative payments.

What I intended to indicate in my earlier response was that our inability at this point to reach that overall framework had not, nor ought it, to inhibit ongoing discussions in particular instances where there was a particular problem. Obviously, if we could arrive at a solution in any of those cases, we would not hold that up until we had a provincial framework.

I think it would be preferable and I think it would be easier for the hospitals and for the physicians to have a provincial framework within which we can then discuss variations in particular circumstances, but I was certainly not prepared to say to anybody, "Look, you have a problem, but you can't do anything about it because we don't have a provincial framework yet." I see both happening.

Mrs Sullivan: Then I'll go back to a similar but a different question to the one Mr Wilson asked. Have you put a draft provincial framework on the table?

Hon Mrs Grier: No, we haven't, and that was where we were hoping to go with the committee that began its work last November. That, as I say, fell apart in February, and we're now discussing with the OMA coming back and its signal that it was going to put some preconditions to its return, which concerns us, because I think everybody has to come to the table and be prepared to discuss the issue fairly openly. That was the kind of discussion my deputy referred to in her response to the question.

Mrs Mottershead: I wonder if I could add to that so there's a bit more context around the early discussions. They revolved around trying to pin down a lot of the data. As you're aware, there is a whole range of activity that also happens in a hospital setting that isn't really related to emergency room coverage.

Because we're into a conversion, part of the discussions had to deal with discussions from the fee-for-service pool, trying to segregate those situations where a physician actually sees a patient, non-emergent, from the real emergency activity in a particular hospital. In order to come to a resolution around what is the appropriate conversion number for moving from fee-for-service into alternative payments, those issues have to be dealt with.

There are many other related issues to this. There are issues of professional fees, hospital technical fees, and it's trying to segregate all of those and reach a decision that all parties are comfortable with that is taking some time and I suspect will continue to take a bit more time.

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Mrs Sullivan: I guess the minister should hear this. Members of the executive of both the Ontario Hospital Association and the Ontario Medical Association have expressed considerable frustration to me in the past three or four days with respect to the fact that a meeting has not been called. The minister tells us today that the terms of reference for a meeting are still being discussed. Why don't you just call a meeting yourself?

Hon Mrs Grier: A letter had gone to them from the deputy inviting them to a meeting. With a date?

Mrs Mottershead: There has been no date established. We wanted to get the names first of the people, because quite frankly, to indicate how seriously the minister and the government are taking this, I actually nominated our two participants on this review committee or special committee or whatever we might call it, and those are the two assistant deputy ministers who have some responsibility for health insurance and physicians' services. That's Ms Jodey Porter and Ms Mary Catherine Lindberg. So I've indicated that at the highest level.

What has happened in previous discussions is that both organizations have delegated to different levels and those people don't necessary have perhaps the clout to actually discuss policy. I wanted to indicate right up front that it's a very serious issue, that we want to tackle it at the highest level. We want nominations from both organizations of people who will be able to actually have a discussion and a decision that will stick with their parent organizations. As soon as we get the names, the meeting will be called.

Hon Mrs Grier: Dean McMurtry has come, and if we wanted to move into a discussion of distribution and recruitment of physicians in response to an earlier question, I'd be happy to do that for as long as it would have use to the committee.

The Acting Chair (Mr Wayne Lessard): It's Ms Sullivan's time right now. If that's the way she would like it to be used --

Mrs Sullivan: I don't mind doing that, as long as I keep my time and as long as my time is added on.

Hon Mrs Grier: I think it would be very helpful for the committee. I'm in your hands as to how the time is organized. If it can be some of our time, I don't think people would mind.

The Acting Chair: It's up to the rest of the committee members whether we extend the time.

Mr O'Connor: We're in Barbara Sullivan's time right now.

Mrs Sullivan: I've got 15 minutes left, right?

The Acting Chair: Just about.

Hon Mrs Grier: Could we interrupt that?

Mrs Sullivan: Why don't we interrupt it, and then we'll add my 15 minutes on later. Then the government will follow, right?

Mr O'Connor: Pick up the seven minutes that I lost at the beginning of your questioning, I suppose, if you want.

Mr Ted Arnott (Wellington): I'd just like to say I'd prefer not to do it that way. I have a couple of questions I'd like to ask the minister, and I'm not sure if --

The Acting Chair: If we can't do it on consent, I don't think we're going to be able to do it.

Hon Mrs Grier: Well, I think that we have an opportunity, and Dean McMurtry happens to be here from London. It would be a shame, the question having been raised, not to take advantage of that.

Mrs Sullivan: Then I will formulate a question for Dean McMurtry, if he could come forward.

Mr Jim Wilson: Good sport, Barbara.

Hon Mrs Grier: Dean McMurtry from the University of Western Ontario and Jodey Porter, our assistant deputy minister, who have both been dealing with this issue.

Mrs Sullivan: We had earlier in the course of this estimates process discussed, in an introductory way, the entire question of physician planning, resource planning and issues associated with retention and other issues, particularly in remote and rural regions. We know that you've been working along with the other deans on these issues, and we'd like to hear what you're doing.

Dr Robert McMurtry: Are you interested in particular in the committee called the Provincial Coordinating Committee on Community and Academic Health Science Centre Relations?

Hon Mrs Grier: That's the one I couldn't remember what it was.

Mrs Sullivan: Now that we've got you here, there are two issues: One of them is the work of that activity and how it feeds into the government process. The second is how decisions are being shaped with respect to admissions to medical schools over the longer term, how the numbers are developed and how decisions are made, for instance, that existing GPs who are already in practice can't go back for specialty education to enter pathology or whatever. Now all the questions are coming to me.

Mr Jim Wilson: Can you answer this in five minutes or less?

Dr McMurtry: The first committee is the Provincial Coordinating Committee on Community and Academic Health Science Centre Relations. PCCCAR, for short, is much easier. It is under the chairmanship of Dr John Evans. It has representation from experts in the health care field with varying backgrounds, but it's still a relatively small committee of approximately four or five of those, and by the public by virtue of the district health council group, the Association of District Health Councils of Ontario.

That is the senior committee and it has three subcommittees, with a fourth one contemplated. The three subcommittees are, one, the subcommittee on the role and future of academic health science centres; second, a subcommittee on post-graduate education; and third, a subcommittee on underservicing. The fourth or contemplated committee is one in relationship to emergency medicine or emergency services coverage.

This subcommittee is chaired by Dr John Evans, as I mentioned, and reports to the minister through the deputy. The committee has a life that is to run to approximately December 1, 1994. The procedure is that when the committee makes recommendations, then decisions at that committee go to the minister via the deputy minister for acceptance or otherwise.

In fact there have been some positive developments in that regard. For example, we've had some good success in management of the post-graduate complement of doctors -- in other words, people who are in their residency -- and there has been significant progress made in reconfiguration. The subcommittee on post-graduate education recommended it under the chairmanship of Nick Busing of Ottawa. That came forward to the full committee and was approved, and then that was in turn approved by the ministry. So that portion of it is a success story.

We continue to have troubles, however, because of the budgetary restraints, and in particular on the clinical education budget. We are left with a choice of taking physicians who are graduating from medical schools and saying they can't have employment and/or limiting re-entry. Neither proposition is attractive. We see that in our post-graduate training there is a readiness by all the schools, I think it's fair to say, to look at very different models. and there is an integration of the subcommittees in this regard.

In summation, the subcommittee on the role and future of academic health science centres is increasingly stating that we should not be so much centres as networks and our number one mission is to be accountable and to network with our communities. It's a very important shift in paradigm and I won't elaborate on it now, but that very clearly in our process is the message that is forthcoming. That relates to human resource planning, for medical folk in particular.

In terms of the post-graduate committee, how do we make decisions about admitting doctors to post-graduate training etc? The answer is that historically we have allowed them to have choice, and what we are increasingly shifting towards is saying we won't do it in terms of supply-side but rather in terms of needs-based. We want to make shifts so that our post-graduate folks are heading towards areas of need.

We are constrained by two things. One is the budget for the clinical education budget. We are down quite a number of positions, so re-entry is currently being lost as an option. The other is that we have to make changes ourselves, because quite often, for example, if you wish radiation oncologists, it's something of what we would call a 12-year solution. From the time you make a decision it's what you want, it could take a lot of years before the person is actually in a practice site.

The option we want to consider much more is taking family physicians and giving them special training in a particular area, be it psychogeriatrics or inner-city medicine or radiation oncology, and saying, "Why don't you pick up on perhaps 80% of what a specialist might do in that year, and we will make sure we can provide you with the skills"? There is a readiness at the medical schools to do that. Like all things in life, it's not perfectly straightforward. There are issues of accreditation and acceptance by various licensing bodies, but we see it as being achievable.

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If given the opportunity, we see that there are some very exciting ways in which we can deal with human resource shortfalls in ways that we haven't done in the past. What we're dealing with, of course, is the whole issue of health reform, and that health stratagem is the affordability crisis that confronts us all. So our options are constrained.

Mrs Sullivan: I'm interested in and pleased with the emphasis on a needs-based planning approach. You have mentioned a couple of constraints, one of them being the clinical education budget. Are there constraints as well in the availability of predictive data with respect to disease incidence or demographic profiles or other epidemiological data that would be required to identify specific long-term shortages in specialties or in subspecialties, and the greying of specialties such as surgery and pathology?

Dr McMurtry: Our information is inadequate. The fundamental overview is that we have a surfeit of data but a shortage of intelligence or good information, I hope not of human intelligence, but we have a shortage of good-quality information. We need to get better at it, to be frank. I'm hopeful that something will be forthcoming in regard to health intelligence units in each of the regions, where we get much better at doing these predictions and working with the ministry and others to be better at predicting. Your criticism is well founded. Our information isn't as good as it could be.

Mrs Sullivan: I really think it would be too long a discussion to talk about the academic health science centres. What would be, however, the role of the fourth group that would be set up with respect to emergency services? Would you basically be doing an analysis of all emergency services, including hospital-based, ambulance-based, or what in fact is the task of that new subcommittee that's proposed?

Dr McMurtry: At the moment this is a proposed subcommittee, so my answer will be somewhat speculative in terms of how I see that it should be dealt with. An emergency, for the sake of discussion, is defined as a condition or problem that, if not intervened with within 24 hours, will result in a predictable compromise of outcome. If you don't do it within a day you're going to have a problem, to put it bluntly.

Obviously, emergencies range from the minute-to-minute ones down to those that can wait towards 24 hours. When you are contemplating intervention at that level, then you must deal with it all the way from the moment of onset of illness or injury until definitive treatment. That picks up on a lot of pre-hospital issues such as ambulances and retrieval, advanced life support in the field, very crucial elements of communications, the issue of how hospitals network with one another. For example, someone may go to a smaller hospital and require backup from a larger facility. So the elements of emergency embrace a lot of issues within the first 24 hours.

I can recall, when I was involved in trauma care, that we would identify as many as 22 professionals whose expertise needed to be brought to bear in order to deal with somebody who is seriously injured, for example. That would all be required within the first 24 hours. Doctors certainly are a very important part of the piece, but so too are many others. It's a complex issue.

What we want to do, when we are looking at this, is to look at the network through the province and see to it that we have sufficient support, that when people are suddenly ill or injured, they can get expert advice quickly through communications technology and be transported quickly to where definitive care can occur. That's as quick an overview as I can give it.

Mrs Sullivan: I think it's an interesting fit with this committee because it certainly addresses a multidisciplinary and multisite approach. One of the things, I suppose, that's a little bit of a concern about the post-grad element of your committee is that it doesn't link into other broader human resources planning. We've got the docs isolated over here and then the nurses and nurse practitioners are here and somebody else is over there, and ne'er the twain seem to meet in terms of what in fact our needs are in terms of total human resources over a longer period of time and how that training would be delivered.

Dr McMurtry: We need much better linkage. The interesting thing is that because of the pressures that are being brought to bear, all over the piece there are hospitals and other organizations that are making judgements and doing what are called provider substitutions; in other words, changing the people who are doing various tasks in order to make it work.

I think one of the interesting things we might do is to do an inventory of that, because I don't know of a major teaching hospital that at some level isn't involved with provider substitution. That's the world from which I come. I suspect if you go to some of the smaller centres, you'll find exactly the same kind of thing going on.

So I think all over the piece on a local basis you're seeing provider substitution. Your point was, shouldn't the various groups be talking to each other? The answer is yes. I think that many of us would invite the challenge to put forward new models to do exactly that.

Hon Mrs Grier: I was going to suggest that perhaps Jodey could respond to that.

The Chair: I don't care which one of you goes. It's helpful if you go through the Chair, and then I can decide which of the two of you can go. Mrs Sullivan, we're coming to the end of your cycle, and I have to come to Mr Wilson, but if a short answer is anticipated.

Mrs Sullivan: I have just time to ask one more question.

Hon Mrs Grier: I was going to suggest that perhaps Ms Porter might want to expand on that, because the whole human resource planning, not just for physicians, is part of what she has been involved in. She could give a quick response on that.

The Chair: Ms Sullivan, would you like that expanded?

Mrs Sullivan: No, thank you. I've got three more minutes, right?

The Chair: Yes.

Mrs Sullivan: I want to move to a completely different section of the estimates. I'd like to have a full briefing note written, not today, with respect to compensation for midwives at the various levels, basically to respond with accuracy to some of the questions that are coming forward.

I would also like to know what the status of the mandatory programs review for local health agencies is.

I also saw in the estimates, under the drug benefits program, a substantial increase in the budget for special drugs, from $15 million to $45 million. Am I reading this correctly? I think I am; yes, I am. I'd be interested in knowing what new drugs will be covered or for what particular illnesses.

Hon Mrs Grier: We're looking at volume. This is a demand-driven program.

The Chair: Minister, at best we'll get all of Mrs Sullivan's concerns on the record, and then you could respond in a more fulsome way tomorrow.

Mrs Sullivan: I wouldn't even mind having, once again, a briefing note approach. I would also be very interested in seeing any efforts in a written form that the ministry has made with respect to developing an appropriate pharmaco-economic model.

The Chair: A brief response, and if not, I'd like to move on.

Mrs Sullivan: I'm out of time now.

Hon Mrs Grier: I'm certainly happy to respond on the special drugs. Essentially, it's a demand-driven program run through the hospitals whereby we meet the budgets. We plug in an amount in our estimates and we hope that by better management we may manage to contain the costs, but inevitably it has been over and above that. It does not reflect increases or changes in the program.

Mr Jim Wilson: Perhaps Ms Porter would like to finish the thought she didn't quite get to put on the record.

Ms Jodey Porter: In terms of more comprehensive health human resource planning, we have had a strong focus on the medical establishment. I think it has been of note in Ontario that we are still turning out more paediatricians than geriatricians, despite the aging population. We do, as Dr McMurtry has pointed out, have an issue with radiation oncology. Those are 12-year solutions, so we need to get in in a real and anticipatory way. We've done a lot of collaborative work with the medical schools in terms of medical service planning for the future.

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We have also, and even under the aegis of PCCCAR, Dr Evans's committee, ensured that in fact the majority of representation is not physician representation. Dentistry, nursing, consumers are the majority on that committee. Although we have focused very heavily on the medical establishment, we have at the same time not only been working with midwifery and some of the other provider groups on a one-to-one basis, but also opened up large discussions with various stakeholders from the nursing profession, from the college, from the union, from the academic side.

We've had a series of very productive round tables with nursing. They've come up with an eight-point plan to the ministry. We believe we can in fact implement and work with them to implement all eight points. So we're not solely on the medical frontier. We are opening up other frontiers. I think the perfect solution, the comprehensive health human resource plan is the ideal for the future. No province has achieved it at this stage.

Our view is that through organizations or committees or structures like PCCCAR, getting all the players and all the leaders and the recommendations into one room is a very good, collaborative first step. So that's the beginning for us and we recognize we have a long way to go.

Mr Jim Wilson: I appreciate those comments, Ms Porter. It does tie into something that Dr Evans referred to.

Dr Evans, you talked about post-graduate complement or the residency reconfiguration that you've done but you didn't really have time to expand. What exactly did the committee recommend and what did the government accept in that area? You talked about it as an exciting area where you've made progress.

Dr McMurtry: Thank you for the promotion. I think you called me Dr Evans.

Mr Jim Wilson: Sorry, Dr McMurtry.

Dr McMurtry: No apology is required. I'm thrilled. Your question is what actual through-puts have we had in terms of changes?

Mr Jim Wilson: Yes.

Dr McMurtry: What we've been able to accomplish is, first, a method by which we can have a clear identification of all the post-graduate activity that has been going on in the province. We've set up what is called a pool proposal or model by which we can characterize a whole manner and variety of post-graduate trainees, fellows, Canadian graduates, international medical graduates etc, so that for the first time we have a strong hold on the issue of exactly how many players we have, how many are being trained and what their backgrounds are and where they're heading to. So the acceptance of the pool proposal was very important.

The second accomplishment from the post-graduate side was that there was a redistribution of residents among the schools to achieve more regional equity, which hadn't existed before.

A third achievement which is under way, which has some significance, is, the deans of the medical schools, a fractious group, to be sure, have come together in an agreement to realign further the post-graduate programs and to create increased flexibility in the post-graduate slots to increase our ability, to increase our flexibility, in terms of responding to needs and to give residents choices as to where they train, and thus reinforce excellence. This agreement is just in the past week and represents quite a departure from the way it has gone historically. All the schools have worked together on that outcome.

Mr Jim Wilson: I appreciate your comments because, as I said earlier, we had a meeting a few weeks back with Ms Porter regarding the initiative put forward by Dr Peter Wells of the Collingwood General and Marine Hospital, and I expect the answer is that specific proposal hasn't been reviewed yet by your committee. But perhaps Ms Porter would like to comment on that.

Ms Porter: Actually, we have invited Dr Wells and he has confirmed his attendance at the next PCCCAR meeting, which I believe is June 22. He'll be making his presentation, which he made with us a number of weeks ago, to that group. That will be part of the ministry's priorities in terms of rural medical practice, to negotiate with the deans in terms of available training spots for the next academic year.

Clearly, rural family practice and rural emergency practice are critical issues for us today. We see the training establishment and the kinds of proposals that are brought forward to us by practising physicians and teaching physicians like Dr Wells in smaller communities as extremely vital in reaching the longer-term, and even the shorter-term, solutions.

Mr Jim Wilson: It sounds from Dr McMurtry's comments as if there might be a good fit there with what Dr Wells has come up with, independent of the work of the committee.

I do have a question, though. As you said, you're moving away from supply-side to needs-based. I'm just wondering, in rather layman's terms, how you're going about, in this day and age, identifying shortages of physicians by whatever classes in the province, in the rural areas. Are we still using doc-pop ratios? Can you just explain on that how you're identifying need and, secondly, need with respect to specifically the shortages we have in certain specialties?

It's a very controversial thing out there when you're talking to individual physicians. For instance, last night in Owen Sound they were indicating that they're always shortchanged because the ministry never identifies need properly in their area. Certainly physicians in my area of the province feel the same way. They feel that the statistical approach taken so far is unfair, inaccurate, whatever language they use to describe it. Is that changing?

Hon Mrs Grier: Mr Wilson, you can't hold Dean McMurtry responsible for the deficiencies of the ministry.

Ms Porter: Shall I speak to deficiencies?

Mr Jim Wilson: Well, whoever would like to speak to that. I seem to be identifying need. There are some new frontiers being broken on this.

Ms Porter: For years what has been used in Canada and what we're still using as base data in Ontario is the doc-pop ratio. That doesn't work. I think it's a tool, it's one tool, it isn't the complete solution.

What we're working on now, again through one of the subcommittees of PCCCAR, chaired by Dr Paul Humphries from Thunder Bay, is in fact a needs-based assessment tool that could be used by communities as well as the ministry, not only to look at physician requirements, because frequently, although the most chronic need or the acute need -- no pun intended -- is identified as a physician issue, frequently it's a shortage or a way of using other providers in the system, particularly nursing, for example.

That piece of work, which has been a tough piece of work for that committee, and it's a multi-stakeholder committee -- people from smaller communities in Ontario, the OHA, the associations of interns and residents, the medical schools, a number of provider groups -- has been ongoing. They are going to be working through the summer and we're going to have that methodology, that tool from them in September.

At the same time we've been working with the chairs of family practice from across Ontario to look at how family practice is and isn't working in smaller-town Ontario. We've had some very, very interesting results which we'd be happy to share with you, but that's research work and it's not high-flown research. It's very practical about how medical service is and isn't working. I think it's very important to the next steps we take in terms of putting a better planning system in place in the province.

Mr Jim Wilson: Dr McMurtry, did you want to respond to that?

Dr McMurtry: There are a couple of things I was going to say. One is going back to an earlier question, and that is that under the Royal College regulations it's acceptable for trainees to have six months in a community setting in their post-graduate program, which is something we could take advantage of. I mention that because we do have that accreditation issue.

Another difficulty we have with doing some of the things we'd like to do is that from a policy standpoint we want to do the re-entries in all these new models, but from the fiscal side we're short of positions, and it's getting worse for 1995-96 from all information that we're getting.

In other words, if there is a flexibility situation that we're going to have to deal with, so that from a policy standpoint, as I see it and speaking as a dean, we agree and we see perfectly eye to eye with the direction we want to head, but from a fiscal standpoint we're being very compressed on positions and faced with some unattractive choices.

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The next point I was going to make is that a man at the University of York in England defined "need" as the capacity to benefit per unit cost. It's where we should begin. When we see people who have needs, there may be any number of mix of providers who might make a difference. The place to start is, "What's the need and what is the best match of providers that can make a difference?" as opposed to assuming it needs to be a particular provider group or groups.

Need definition is very elusive, and doc-pop ratios for sure don't work. For example, internationally the ratio of docs to nurses ranges from six to one nurses to physicians in England, to four to one in Canada and one to one in Spain. That's without even talking about any other providers. There's a real mix of what each is doing from country to country. So defining "need" is certainly challenging.

The last comment I'd make is that academic health science centres should be networks, so they should work with the people in their community to be sure that we're helping them with their human resource planning. When we say "academic health centres" we mean all the disciplines, not just the medical. We should have an active interface to try to help.

Mr Jim Wilson: Thank you very much. I think Mr Arnott has a constituency question he wants to ask.

Mr Arnott: I have a question to the minister.

Hon Mrs Grier: I was happy to see Dr McMurtry and thank him most sincerely for having given us the time and coming in specially. Thank you very much indeed.

The Chair: Just think: After the next election you're going to make a fabulous Chairman.

Hon Mrs Grier: I think I make a fabulous Health minister and I plan to continue.

The Chair: Let's both stay focused then.

It was a hell of a presentation out there. Thank you, Minister. I don't know why you type up these lists with everybody's name and title for us. It's just wonderful.

Hon Mrs Grier: I don't.

The Chair: Please, don't be deterred by all this, Mr Arnott. Proceed. I'm sure the minister was about to listen to your question.

Mr Arnott: I'll put my question to the Chairman or the minister, whoever wants to answer it, but it is a serious question, to get back to a serious issue. I received a telephone call from constituents back in November of last year, Gerald and Edith Henry from Clifford. Gerald has arthritis. He's been on medication called Indocid for some time. It was one of the drugs that I believe was delisted some time ago by the government as no longer eligible under the Ontario drug benefit program.

Now, of course, I understand there's a mechanism whereby if an individual wishes to continue receiving the drug that they had been receiving previously and if they have the doctor's letter indicating that the specific drug has to be the one that's supplied for their condition, that a generic substitute is not applicable, the ministry will review that and determine whether or not it will cover it under the Ontario drug benefit program.

We tried to follow that process. I had Mr and Mrs Henry write me a letter, again back in November. I brought this to the attention of Mr Y.S. Drazin, who's the director of the drug programs branch. We had documentation from the family doctor as well indicating that the individual needed this Indocid drug. I guess we sent the letter in December. We received a response back from Theresa Firestone, who was the director of the drug programs branch right before Christmas, indicating that the ministry would not pay for Indocid.

Mr Henry was quite disappointed by this decision and asked me to bring it to your attention as minister, which I did, writing you -- I guess the date here is in February -- again with a handwritten letter from their family physician -- I'll give you a copy of it; I'll pass it to you, Minister -- again requesting that this drug be allowed and that it be paid for under the Ontario drug benefit program.

It was February that this letter was sent to you. I wrote you again in March and I wrote you again in April and I've not received a reply. I'm just asking you for your personal undertaking to look into this matter on behalf of my constituent and see if there isn't complete documentation there which would allow for him to receive this drug. I believe it should be retroactive too as well, given the history of it.

Hon Mrs Grier: I certainly apologize for not responding. It's not the minister who decides what drug would be dispensed. It is the Drug Quality and Therapeutics Committee that makes the recommendations from a therapeutic as well as a cost-effective point of view. In the case of an application for a special drug, again, that would be reviewed objectively as to whether in fact the request was justified.

I could ask Mary Catherine Lindberg to come and talk to the process, but I feel very uncomfortable talking about an individual case in this kind of forum, though I would certainly give you my undertaking to examine the correspondence.

Mr Arnott: That's all I request.

Hon Mrs Grier: But I think it probably would be helpful if Ms Lindberg could describe the steps and the process so that people are all familiar with what happens.

The Chair: It may be, but I'd have to ask Mr Arnott if he wishes to use the balance of his colleagues' time with an explanation of the process or if he had other questions.

Mr Arnott: I think I gave a summary of what the process was, as far as I understand it. If I'm mistaken, perhaps you could briefly say exactly where I was mistaken. But I understand there is --

Ms Lindberg: I'll look into it, but the process is, if it's Indocid, Indocid is currently listed but it has a generic substitute. All the doctor needs to do to get the brand name of a generic is write what we call a PC-34, which is a handwritten prescription by himself, signed by the doctor, and the pharmacist then remits it and gets Indocid and gets paid for the price of Indocid, not paid for the generic price.

Mr Arnott: Yes, we've done that --

Ms Lindberg: If it was extended-release Indocid, which is the one we delisted, then the contention is that it would be just as valuable for the person to take the Indocid and not the Indocid long-acting because of the kinds of reactions and side- effects you get from an SR.

So with Indocid SR, which we delisted, you probably would not get it filled by special authorization, because the DQTC felt very strongly that it should not be a benefit, and there were health reasons for it not being a benefit. If the patient needed it, he'd be better to take it as a regular dose on a regular dosage schedule, and that drug currently, the regular drug Indocid, is covered.

We'll look into it, but I think if it's the SR, we have not been given exemptions on that, mainly because the DQTC, which makes all the decisions on special applications, feels strongly that for better health effects, you should take it in a non-sustained-release form.

Hon Mrs Grier: In other words, the drug is available, but you would have to take it a number of times a day, as opposed to the request which was that it be in the slow-release form, which would enable the patient to only take it twice a day. But they can get this drug if it's one that their doctor feels they need to have. I will certainly look into the correspondence, because it's unacceptable that you should not have had an answer, and I apologize.

Mr Arnott: I appreciate that, Minister. Thank you.

Mr Jim Wilson: Minister, I want to go to vote item 1502-6, the loans-based financing, Jobs Ontario Capital. I have a personal interest in this with the county of Simcoe and hospital capital projects that have been promised over the years. I think every year in Health estimates I ask people very similar questions, and I'm going to ask you --

Hon Mrs Grier: Your other colleague from Simcoe has the Royal Victoria well in hand after many years of promises.

Mr Jim Wilson: That's very interesting that the Royal Victoria is well in hand, but I'm worried about the other three hospitals as well.

I saw in Mr Laughren's budget only a mention of the Royal Victoria, at $98 million, and I'm a little concerned that one hospital's going without the others. I would ask you to bring us up to date on all four hospitals, that is, Soldier's Memorial in Orillia, Royal Victoria in Barrie, General and Marine Hospital in Collingwood and Stevenson Memorial Hospital in Alliston. They were part of a package and very concerned when they saw the budget come out that only one hospital was mentioned.

Secondly, I would just mention that obviously with the new off-book, loans-based financing, it's very difficult to find out from the Ministry of Health estimates exactly what capital projects the ministry is intending to proceed with this year. So specifically with the capital allocation for Simcoe county, can you bring us up to date on the four hospitals, please?

Hon Mrs Grier: Okay, let me just make the point that references in the budget were to major capital expenditures, and the absence of the mention of any others ought not to be taken as an indication that they are not under active consideration.

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With respect to the Simcoe, as I understand it, in September 1992 the ministry reconfirmed a commitment for capital projects in Simcoe county, and the DHC has been working in order to make sure that the functional programs that the hospital submitted are in line with the recommendations and the approach that the DHC is taking on a district-wide planning approach. Perhaps the deputy wants to add to that.

Mrs Mottershead: I was going to suggest that we have the assistant deputy minister for the institutional group here, Mr Mark Rochon, who may have more up-to-date information on those projects.

The Chair: Could you come to the microphone, please? I believe you've already been suitably introduced. If you could be seated and respond.

Mr Mark Rochon: Thank you. What I could do is get you some specific information on the status of those projects for tomorrow afternoon.

Mr Jim Wilson: That would be most helpful because, obviously the communities don't understand functional planning and they don't understand a lot of the hoops that they seem to have to go through to get these projects up and going, so to shed any light on it would be most helpful at this point.

Particularly, Minister -- and I think it's a question for you, given that you're heading into the last year of your mandate -- are you hoping to make these capital announcements, actually get things moving, building, prior to leaving office next year?

Hon Mrs Grier: I think the timing depends, quite frankly, on the planning. Let me put this in the way in which in fact it is unfolding: When we took office, there was a wide range of commitments that had been made for capital projects. There had been no dollars allocated or identified in order to live up to those commitments, so one of the early things we did was undertake a review of many of those.

The other thing that has happened is that the whole approach to health care and to capital projects and institutions is changing almost monthly as the planning occurs and we move away from institutions to community-based, to ambulatory, to out-patient service increases as a way of providing a better quality of service.

Many of the projects that appeared advisable even five years ago are no longer consistent with the plans that the district health councils are preparing or with the analysis that's being done of the needs of various communities. So it is critical that no capital planning or commitments be made until there is in fact a plan for the rationalization of services within a particular region.

I know, having met recently with the Simcoe district health council, that it's one of the most active district health councils, with a wide range of volunteers looking at all aspects of health planning, and the movement ahead of Royal Vic is something that is consistent with its role as a regional hospital to serve that area.

The functions of the other hospitals need to be conclusively determined before commitments can be made for investments in those facilities, and it's the status of those discussions that I think the assistant deputy minister can bring back to the committee tomorrow.

Mr Jim Wilson: I appreciate that. I would ask Mr Rochon, with respect to reading the estimates this year, there's $150 million that's going off-book to the Ontario Financing Authority, and I'm just wondering what that is based on. Does the ministry have a series of projects that they expect will proceed to construction this year? I'm wondering if that list is available. What is the $150 million based on? What is actually going to get built this year and what is deferred until other years?

I'm also interested in the relationship between the OFA and the ministry, and exactly how this works. I imagine the ministry gives approval. Do the hospitals themselves actually apply to borrow the money from the OFA, or how exactly does that work?

Mr Rochon: Perhaps the details of the relationship of the OFA can be dealt with by the deputy or someone else. But in terms of the specifics, the $150 million deals with projects that exceed $1 million, so anything less than $1 million is dealt with on a grants base as opposed to a loans-based approach. We have projected out beyond 1994-95 for the allocation of capital dollars through the loans-based program and we can provide the estimates that we have for specific projects under way in 1994-95.

It's quite an extensive list. Some of the issues relate to health and safety concerns and are less than $1 million on the grant side. Others are much more significant including, for example, the project on University Avenue with the Princess Margaret Hospital, which is a significant share of the expenditure in this coming year. If you'd like, we can provide some detail --

Mr Jim Wilson: To make your life easier, I'm really interested in the projects over $1 million that will be funded through the OFA. Does the deputy want to comment on the mechanism? I was at a hospital board in eastern Ontario two weeks ago and, to use the term, for lack of a better one, ordinary board members don't understand that the money is essentially being borrowed now from a capital corp. Perhaps you'd like to just explain what the mechanism is there.

Mrs Mottershead: The Ontario Financing Authority is the borrowing arm for capital projects in this province, based on a plan that's submitted first by the hospital on how much money it will require in terms of construction. That in turn gets aggregated by the ministry and gets forwarded to the financing authority for all projects under construction so that they are aware how much money is required and how much they need to borrow, not just for the Ministry of Health but for the broader public sector organizations.

In turn there is an agreement that is developed that is the loan agreement between the financing corporation and the hospital which actually lays out the amounts to be borrowed as well as the amounts payable. The Ministry of Health does provide for an operating subsidy to the hospitals so they in fact can repay the debenture that they've agreed to.

Mr Jim Wilson: It's that latter point that's sticky with administrators, and this is not only with hospitals but on the municipal side of that too. Yes, there's an agreement, yes, it's a 20-year amortization period, yes, there are semiannual payments through the operating budget from the ministry to the hospitals, but what if some government 10 years down the road says, "We're not going to pay these grants any more"?

What assurance do hospitals have in this case -- and it also applies to municipalities and everybody else on the new borrowing scheme -- that these grants will continue to flow year over year? How solid is the agreement between the hospital and the ministry? How binding is it?

Mrs Mottershead: When the arrangements were made on financing, we also took the opportunity of streamlining a number of regulations that had been established over years that were dependent on certain funding formulae and certain processes, whether they were emergency, health and safety or environmental projects or hospital projects.

In making those changes and in streamlining the regu lations, we actually developed one that dealt with capital financing. In that regulation there is an explicit obligation that the government of Ontario will ensure that there are sufficient operating dollars to deal with the payback of the particular debentures. We have language in regulation. We were able to do that over a year ago.

Mr Jim Wilson: Minister, I have a question with -- oh, we're done?

The Chair: We're almost there.

Mr Jim Wilson: This may perhaps be a very simple answer. On vote item 1502, dealing with health system management, health insurance and benefits, I'm just wondering, with the new health card coming in, seeing that there are decreases actually throughout most of this budget, in this vote item anyway, except for employee benefits, where exactly is the increase in dollars for the implementation of the health card beginning in February 1995? This may be a simple answer.

Mrs Mottershead: They are not in the Ministry of Health estimates as of this point in time. The government did undertake to have a look once we've put together the complete financing approach to this. I believe in the overall government contingency -- if you look at the budget, there's a line called "contingency" -- that would hold the provision for our health card estimates.

Hon Mrs Grier: We have treasury board approval for an amount. As we do our work on implementation, we'll come back and refine those numbers, which will then be part of our actuals for this year.

Mr Jim Wilson: I knew the answer was that you don't have it in here, because I can't find it. It does lead one to the question of how committed you are to February 1995.

Hon Mrs Grier: Absolutely, totally, and we have the funding approved by the treasury. It shows in the Treasurer's corporate accounts at this point.

Mr Jim Wilson: I don't particularly want you to be all that committed. So if you want to leave it in contingency and think up a new one, I'd be happy about that.

The Chair: I should indicate that the matter that you raise in a general sense has been the subject of review by the Provincial Auditor and two other committees. A joint meeting of the three committees dealing with financing matters is undertaking to look at that reporting aspect.

Hon Mrs Grier: You mean the financing association?

Mr Jim Wilson: The financing authority.

The Chair: Yes. It is now 6 of the clock. We have four hours, three minutes remaining. It may necessitate meetings being scheduled for next Tuesday, June 21. The Chair is open to discussions prior to the start tomorrow of any interest in modifications to that schedule.

There being no further points, this meeting stands adjourned.

The committee adjourned at 1803.