Assemblée législative de l'Ontario

MINISTRY OF HEALTH

CONTENTS

Wednesday 15 June 1994

Ministry of Health

Hon Ruth Grier, minister

Margaret Mottershead, deputy minister

Mark Rochon, assistant deputy minister, institutional health group

Jodey Porter, assistant deputy minister, health strategies group

STANDING COMMITTEE ON ESTIMATES

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

*Acting Chair / Président suppléant: Lessard, Wayne (Windsor-Walkerville ND)

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)

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 Arnott

Also taking part / Autres participants et participantes:

Naylor, Dr David, chief executive officer, Institute for Clinical Evaluative Sciences

Clerk / Greffière: Grannum, Tonia

Staff / Personnel: McLellan, Ray, research officer, Legislative Research Service

The committee met at 1547 in committee room 2.

MINISTRY OF HEALTH

The Chair (Mr Cameron Jackson): We have approximately four hours remaining to complete the Ministry of Health estimates. Mr Wilson was our last questioner. Before I recognize the government party for questions, has the ministry any written responses that flow from questions that have not been answered?

Hon Ruth Grier (Minister of Health): Not at this point, but Dr David Naylor from the Institute for Clinical Evaluative Studies is here in response to an earlier request that he provide information to the committee.

The Chair: Okay. Is there any problem getting the written responses? Is it fair for the Chair to ask on behalf of the committee if we might have those prior to the completion of estimates, which will occur next Tuesday?

Hon Mrs Grier: Certainly that was our intention.

Mrs Margaret Mottershead: We will have the majority of those. As a matter of fact, we do have some of the responses, except that unfortunately the number of copies weren't made on some of them, so even by the end of today we might have some of those responses tabled with the clerk.

The Chair: We're not afraid of doing the photocopying, if that was what you were trying to share with us.

Mrs Mottershead: That's fine. The capital list is available. I know the assistant deputy minister has it with him, if the clerk doesn't mind doing that.

The Chair: The clerk doesn't mind. It's helpful to the committee that we can get as much of that information in their hands as possible and it makes for crisper questions and actually it's extremely helpful. We appreciate that, Deputy.

My first speaker is Mr Wessenger.

Mr Paul Wessenger (Simcoe Centre): I have a question to the minister. It's related to the whole question of hospital restructuring. I know we have the joint committee with the OHA with respect to dealing with the issues of restructuring throughout the province, and I know specifically we've been dealing with particular areas, particularly the Windsor area, but I would like to know what progress the joint committee is making with respect to setting out some principles with respect to restructuring the hospital system; in particular the issue of how we intend to deal with the growth aspects of the province, the question of whether one of the principles will be rewarding efficiency of hospital operation, and lastly, the question of whether we're looking to move towards a more regionalized model of delivery of hospital services.

Hon Mrs Grier: There's certainly a lot in that question and perhaps I could ask the assistant deputy minister, Mark Rochon, who has been dealing with that and would be our representative on that committee, to respond in some more detail.

Let me say that I think we have made enormous progress with respect to hospital restructuring, whether it is that hospitals began voluntarily to do restructuring and then realized that it's like dropping a pebble into a pond: the ripples go out and out and you have to look not just at the hospitals but at the other institutions and then at the community-based services. Windsor, of course, is the example that has gone the furthest, but all of the DHCs are doing it and so it was felt to be appropriate to try to provide some framework and some guidelines within which that would occur. That's what Mr Rochon can speak to.

Mr Mark Rochon: I just want to make sure I have your questions down properly, Mr Wessenger. I have restructuring, the principles around restructuring, and --

Mr Wessenger: Yes. What I would like to start with is an update with respect to the progress being made by the joint committee with the Ontario Hospital Association with respect to some of the restructuring issues.

Arising out of that were some areas I had some particular concern with, and that is that I think certain aspects have to be recognized. I know in the past we have recognized population growth, and particularly aging population growth, with respect to funding decisions concerning hospital restructuring.

I know that many of the hospitals I discuss the issues with have always been concerned about the aspect that they would like to see the funding system moved towards rewarding efficiencies in hospitals rather than rewarding the inefficiency.

Lastly, the issue that's often raised is the whole question that perhaps greater efficiencies could be achieved in the system by having a more regionalized delivery of some of the services that are now delivered at the tertiary care hospitals in the larger centres. I know there is some movement in that regard in certain of the services.

That initially probably gives you enough to deal with.

Mr Rochon: If I could begin with restructuring, and you asked specifically about the JPPC, the joint policy and planning committee work, for those who are not aware of the joint policy and planning committee, the JPPC is a joint organization. It's a secretariat that is made up of the Ministry of Health, hospitals and the Ontario Hospital Association, and it has a number of working committees that are dealing with reform topics in general.

One of them is the management committee, and under the management committee there is a subgroup looking at restructuring. They have recently completed a paper that outlines between 10 and 12 principles dealing with restructuring the hospital system in Ontario. Those principles deal with issues such as access, quality, critical mass, the voluntary nature of restructuring exercises in Ontario, and issues of affordability.

The Ontario Hospital Association and ministry have looked at this in draft form. Their view is that it ought to be the subject of a much wider debate and discussion across Ontario and with other stakeholders involved in restructuring exercises. That debate will occur, I suspect, over late summer and early fall. But the fundamental principles around restructuring are those of access, quality, critical mass and affordability.

Many of the restructuring exercises under way are looking at issues of, given certain facilities' experience and expertise in areas, are there opportunities to consolidate programs and services? You asked a question about specific restructuring activities, and I'm wondering if there's a particular community in mind that you'd like to focus in on. If I don't have the answer here, I can go and make sure you get it. Are you interested, for example, in Windsor?

Mr Wessenger: Perhaps I will raise the particular hospital that raised the concern with me when I visited, and that's the hospital in Newmarket. They raised the issue of the fact that they felt they were delivering services at a very efficient level and had achieved a high level of efficiency compared to many other hospitals. They were concerned about the fact that the funding formulas perhaps did not adequately recognize the aspects of growth and the aspects of a hospital that was more successful in achieving efficiencies. I know from my discussions with many hospitals across the province that the same issues have been raised at other hospitals.

I think their concern is that with these principles that are going to be developed, are there likely to be some principles involved which will recognize some of these aspects? I think the other aspect that has been raised, quite frankly, is the concern that perhaps some regions are relatively overfunded and some regions are relatively underfunded. That's another issue that's certainly a concern.

Mr Rochon: The question about growth and equity is a very important one. If we go back about four or five years, the Ontario Hospital Association and the ministry began a process that was termed "transitional funding." The exercise was aimed at achieving a more equitable basis of funding hospitals in Ontario. Over about a four-year period, approximately $150 million was allocated through what is termed "the equity formula" to hospitals on the low side of the cost equation.

What we do in Ontario is, we place hospitals into peer groups according to the services they provide. We have, for example, two teaching hospital peer groups and five or six community hospital peer groups, and the hospital's costs are compared to the peer. Up until this year, if a hospital's were below the average, it received additional funds, recognizing that there was an issue of equity. Through that formula, as I mentioned earlier, we allocated approximately $150 million.

What we are doing this year is called reallocation. What we have done, recognizing that for 1994-95 we are operating in a zero-sum environment, is we've decided to look at hospitals at the high end of the equation, to take money from hospitals that perhaps have higher costs than others for the work they perform and reallocate it through the system.

We have identified, through a joint process involving the Ontario Hospital Association and hospitals, 22 hospitals that have been notified that their funding will be reduced in recognition of our desire to move towards a more equitable system of hospital funding. These 22 hospitals have been provided with a six-month notice period, and they will also be provided with an opportunity to appeal this decision.

The recommendation that we have implemented was also taken with the full support of the board of directors of the Ontario Hospital Association. So we have the full support of the industry in this move.

You will hear from those who are not in favour of the move that there are too many warts in the formula to allow us to use it for something as dramatic in Ontario as reallocation.

What we have done is establish some pretty wide boundaries around the average cost to make sure that the warts are well insured by parameters so that a hospital would not find itself going less than two standard deviations from the mean and it would not find a reduction in its total budget of more than 3.5% on a fully annualized basis. So we're trying to move in the direction.

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The other piece of very interesting work that is being discussed right now is around looking at establishing specific rates for work that hospitals perform. What I think this will do will be to promote a greater accountability for the work that hospitals produce and for the funding that they receive.

The idea that is being suggested is that specific rates would be established for procedures. Those rates would be adjusted, for example, if you operated teaching programs or if you were in remote areas and so on, and the work you perform would be subjected to an annual planning exercise whereby you would commit to produce so many units of service in your institution at such a rate.

Again, we think this is in the same direction as promoting a more equitable funding system for Ontario hospitals. As part of that, we would also deal with the question of growth and how to deal with growth in areas like Simcoe county, York, Durham and so forth.

It's certainly an issue that has a lot of support for development in the field and, in my view, working these out in consultation with the group that actually has to implement it is a very important principle we're trying to continue to promote.

Mr Wessenger: Thank you. I think that's certainly given me a good background.

The Chair: Very good. Any other questions?

Interjection.

The Chair: No, I meant of this deputant. If not, then --

Mr Larry O'Connor (Durham-York): I think Wayne probably does about the Windsor hospital.

The Chair: Then please go ahead, Mr Lessard.

Mr Wayne Lessard (Windsor-Walkerville): Madam Minister, you'll be happy to know that I don't share the view of the Liberal member, Ms Sullivan, when she talked about people in Ontario facing a crisis in confidence in health care. I think things are going fairly well in the Windsor area, and part of that is the result of the major restructuring efforts that are going on there that I know you are quite well aware of.

I wonder whether you could tell us, or someone from the ministry could tell us, what might have been learned by the ministry through that experience and whether you're pleased with the progress that has been made so far.

Hon Mrs Grier: Maybe I should start off on that one.

The Chair: I'd like to dismiss the gentleman. I had a speaking order, but --

Mr O'Connor: I thought this would be a hospital question.

The Chair: That's fine. Thank you very much.

Mr Derek Fletcher (Guelph): Some may after. Let Wayne ask his question.

The Chair: Go ahead. The question is to the minister. Fine. Thank you very much.

Hon Mrs Grier: I was just going to say I may need to call Mr Rochon back if we get into details, but let me say generally to the member that I think the Windsor reconfiguration exercise has been an incredibly creative example, one that everybody is looking at, where a community has come together, stood back from its own institutions to a certain extent and said, "What's in the best interest of our community, and how can we plan for a health care system for the future?"

The result has been recommendations that they go from four hospitals to two, which is very dramatic, but along with that has gone a commitment from the government to put in place, as a result of the savings achieved from the reduction in the number of institutions, a community-based network of services that will be there to provide a whole integrated system. I think it has really been a remarkable exercise.

What has been learned? I think what has been learned is that, while this process may start with the hospitals deciding to rationalize, they quickly realize that that can't be done in isolation, that they have to involve in their planning and in their final plan all of the other institutions and then beyond that to the community-based services.

If, for example, you acknowledge that in the future the length of stay in hospital is going to decrease even further, then it follows as the night the day that you have to build up the community-based home care and acute care services in order to support that change. So you can't do one without doing the other. I think that's the first lesson that has been learned.

I think the second is a confirmation of my profound faith in the common sense -- and I still use the word despite its bastardization by others as being linked as an adjective to "revolution" -- of the people of this province that if you share with them good information and good data and say to them, "Here's what's happening; here are the choices we face; we want to listen to you and come out with the best solution for our community," and you do that openly, honestly and in the fullest possible way, people understand, learn and come to the best conclusions and a consensus in their communities. So that was the second.

The third was the value of doing it locally, that the district health council and its steering committee had remarkable courage and put an incredible amount of volunteer time into doing it and that local leadership is critical to coming out with a solution that fits the local needs. As I said in my opening remarks to this committee, Dennis Timbrell had noted that Ontario and Manitoba were the only provinces remaining that put faith in local decision-making and recommendations, so that local leadership was critical.

I think, finally, what we learned was the importance of human resource planning as part of this restructuring. In Windsor the strong history of the labour movement, from being involved in health care, the initiation of Green Shield and protection for people through health insurance and its involvement, as a matter of course, in some of the discussions about local issues brought it to the restructuring exercise, but again rather late in the process.

What I say to other district health councils is, involve the employees and do your human resource planning at the initial stage of your restructuring exercise. They're the people who are going to feel the first impacts of restructuring, they have to be part of the decision-making and they have to be shown how in fact, if there are fewer jobs in hospitals -- there may well be more jobs in the community -- to do that labour adjustment.

It has been a very valuable exercise and one that, while it doesn't fit with what other communities may do, provides some valuable lessons for other communities and is being looked at carefully. We are now into the implementation stage. That is perhaps going to be no less rocky than some parts of the planning stage were, but Windsor is to be congratulated for being the first community that has moved in that direction.

Mr Lessard: I understand the importance of there being local leadership and local involvement in the decision-making. As part of the process, the district health council hired a new director. His name is Hume Martin.

In a speech on Monday he talked about the importance of moving ahead speedily with the amalgamation of Windsor Western Hospital Centre and Metropolitan General Hospital, which is part of the restructuring. He senses that there's some reluctance by the two hospitals to move ahead with that.

He made this statement, "The effectiveness of hospital CEOs was judged not by their commitment to systems integration but by their ability to go to Queen's Park and get more money for their hospital." In making that statement, he still recognizes that there's some reluctance to move ahead and recognize the cost saving that would result from that.

He estimates the saving would be $22 million from the merger, $109 million in capital and redeveloped hospitals and $6 million for a new state-of-the-art information system. He thinks that we might lose those savings if we don't move ahead. The district labour council at its meeting last night -- well, they may try to urge the government to get involved in seeing what it can do to speed up that process. I wonder if there is something that we may be able to do.

Hon Mrs Grier: Let me say that of course the ministry is still very close to the implementation and has been working with both Mr Martin and the institutions as they make the next steps towards implementation of the plan.

I understand that change is difficult. Change is particularly difficult for hospitals that have been used to sending the CEO to Queen's Park and getting the money. But I think the vast majority of CEOs understand that life has changed and that it is critical for hospitals that they become part of the system and that system integration is the way to take us into the new century.

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I was in London yesterday and was very impressed and encouraged by the recognition of hospitals there of how system integration has got to be the way of the future, and certainly I think the hospital wards and the community in Windsor understand that. The whole reconfiguration in Windsor is dependent upon the savings being achieved by the work of the hospitals, so I certainly concur in Mr Martin's encouragement to them to move on quickly.

But let me also say that I think the whole plan there has been a made-in-Windsor solution, that what came out of it was a win-win for Windsor. I remain confident that Windsor can deal with the problems that will arise as they implement, and again it is preferable that those problems be addressed by Windsor. The ministry is keeping in close touch, is certainly prepared to offer advice and information when needed and, if necessary, to attempt to mediate if issues come up that require that. But I think Windsor, because it has done such ground-breaking work, as I say, I have every confidence that it will continue to do that.

Mr O'Connor: I saw Dr Naylor come into the room and wondered if perhaps we'd have an opportunity to entertain a little bit of dialogue. As you come forward to the microphone, the Ontario Health Survey indicated that those with a lower socioeconomic status don't seem to have the same access or don't go to specialists as often as those of a higher status. I wondered whether or not you've had a chance to evaluate that and how we in Ontario would stack up to other jurisdictions.

Dr David Naylor: My name is David Naylor. I'm the chief executive officer of the Institute for Clinical Evaluative Sciences. The institute is a non-profit research corporation. It functions at arm's length from the ministry and from the Ontario Medical Association, which are its two cosponsors.

It's an interesting question. There are a couple of parts to it. The first one is simply, do we have confirmation that there is a differential utilization of GP and specialist services by socioeconomic class and education? The answer is yes. I want to highlight that the differential in absolute terms is small, that the OHS data are somewhat unreliable in terms of pinpointing absolute differences anyway, because they are self-reported data. Unless you look across actual utilization data by social class that break out the specific GP-specialist utilization profiles in absolute numbers, it's very hard to be sure of the precise absolute magnitude of the difference.

In relative terms, and I emphasize that relative summary measures are always to be interpreted with caution, we're looking at differentials that are moderate, not large. Why do they exist? They could exist for any number of reasons. I emphasize that my discussion here is entirely speculative. They may exist because of difference in comfort zone in requesting consultation; they may exist because individuals in lower education strata may feel less empowered to call for a further opinion or call for a consultation; they may exist for a whole host of reasons related to health status.

I would personally be very uneasy about believing that the distribution of conditions for those in lower socioeconomic strata, who have always had an excess burden in morbidity in our population, is somehow skewed such that they could be better managed differentially by general practitioners than by specialists. So I think there is a concern about equity here; there is a concern about outcomes.

Do we have specific data linking these different utilization patterns to overall health outcomes? The short answer is: The data are only ecological. We know that there has always been a correlation between socioeconomic strata and education level and health status, the association I mentioned, but we can't really say which rate is right, whether more specialist utilization by more educated folks is actually a better thing to encourage for those in lower strata or whether this is in fact something that we should discourage for those in the higher socioeconomic strata as we try to move to more of a single portal of entry to the system and more emphasis on primary care and on the family physician as gatekeeper.

So to highlight, the normative judgement about which mix of services is best cannot be drawn from these data. The one normative judgement, however, that I would make is, there is an issue there about equity of access and utilization that does need to be followed up.

Mr O'Connor: Is there any comparative information that we could place against other jurisdictions, the UK or the US?

Dr Naylor: Compared to the US, we obviously look terrific. There is no issue about that. Not only is the US primary care system organized very differently from ours, with much more reliance on the general internists, on the paediatrician, on the gynaecologist rather than on the family physician, but also we have the persistent problem of 30-million-odd uninsured, 15 million underinsured and the existence of deductibles in coinsurance. We consistently see in the US data a much more marked gradient in utilization, not only of GP versus specialist services but of all types of services, compared to Canada. This is obviously one of the strengths of our system.

I would argue that on balance the OHS data would suggest that in many respects medicare, over the last 25 years, has done much of what it set out to do in eliminating the role of class and income as barriers to access, but the job is not complete and clearly there are some opportunities to be pursued for further improvement.

Mr O'Connor: The work that ICES is doing is quite extensive, and I don't know whether there is the same degree of depth being put into it in other jurisdictions. Are there any others and are they finding anything that's astoundingly different?

Dr Naylor: I could take a long time covering that question.

The Chair: You have four minutes left, if you have the inclination to do it.

Hon Mrs Grier: But we have four hours.

Dr Naylor: I'll follow the Chair's direction and take four minutes.

Mr O'Connor: He's going to cut you off anyway.

The Chair: You have four minutes, and I have Mr Fletcher waiting.

Dr Naylor: For the short answer, let's focus on Canada if we can. The Manitoba Centre for Health Policy and Evaluation is doing some excellent work, with a particular focus on population health status and its determinants. They're trying to tease out the interrelationship between utilization and health status in substantial detail. It's a difficult area because utilization is confounded with socioeconomic status, as we've seen in the Ontario Health Survey, so it becomes a soup of causes, effects and epiphenomena not easy to tease apart.

Quebec has a council on health technology assessment headed by Renaldo Battista, again looking at a variety of patterns of technology diffusion and assessment, less of the broad population health focus, but they have also analysed small area variations and surgical rates.

Nova Scotia is talking about setting up similar activity at Dalhousie. Saskatchewan has the Health Services Utilization and Research Commission. I think you'll find that in province after province there is a variety of groups that have been set up to examine the utilization, look at population health status and try to tease apart some of the factors that might contribute to a more effective and efficient system.

The Chair: Do you have another question, because we have two and a half minutes left for Mr Fletcher.

Mr O'Connor: He needs more than two minutes. Maybe what I could ask then is, what are some of the next steps that are going to be studied and evaluated?

Dr Naylor: One of the crucial things is to follow up on the large variation in procedures that we found. For example, coronary bypass surgery, hysterectomy, a few others where we have major variations in utilization.

We obviously have to get provider buy-in to do that, to access charts and review them, but for many procedures there are very well established utilization audit criteria that can be brought into play. It will allow us to get some sense of whether or not high rates necessarily imply some proportion of equivocal or inappropriate case selection -- not always the case, I emphasize -- or whether low rates suggest an access issue, if we examine patients who are undergoing medical therapy who are not having surgical alternatives. So we have a lot of follow-up at the local level to do.

We also plan on reissuing the atlas with a very strong outcomes focus, looking much more closely at the OHIP data, trying to tease apart some of the clinical patterns of utilization rather than focusing on broad expenditure trends. So there is a lot more to do, I think, to make sense of what we found and to get at some of the clinical issues behind the aggregate statistics.

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Mr O'Connor: Thank you. I think the Chair is telling me that's about what we've got for time.

The Chair: That's exactly what the Chair was saying. Mrs Sullivan.

Mrs Barbara Sullivan (Halton Centre): I'm pleased that Dr Naylor is here and I'm going to ask him to stay at the table for the next couple of questions.

I think that the ICES atlas was an interesting one, and frankly I was disturbed at some of the response that I saw in the press which raised the issue almost to a circus-like atmosphere rather than looking at this as being a first step along the way.

I wonder if you could, first of all, advise the committee on what the next step is with respect to analysing the existing data, what the process will be in subsequent years with respect to looking at the data on rate variations in various communities and how you see that work being structured, given your organizing oligarchy, if you like, or the Ministry of Health and the Ontario Medical Association, and yet much of your material in fact refers to other areas of health care delivery, including hospitals and so on.

Dr Naylor: An interesting question with a number of facets to it. Let me start by dealing with the specific issue of rate variation. First, it's important to corroborate the member's statement that in no way are we implying any particular blame.

The issue of rate variation really should be seen as a screening test or a first step in understanding how the system functions. In many instance when data have been teased apart and charts have been audited, there has been a very limited correlation between higher rates and higher inappropriate use of procedures. So we can't always assume that the high rate is wrong or inappropriate. In some cases the lower rate may be one that raises issues of access, and much follow-up work needs to be done.

We have an external coordinating committee which involves representatives from the ADHCO, the district health council organization, from the Ministry of Health, from the Ontario Medical Association and also the Ontario Hospital Association. The external coordinating committee will be meeting over the next couple of months developing some work plans to relate to atlas follow-up and bringing them back to JMC for further discussion.

One of the points that's obviously important is that if we are to access charts and to begin to look at indications for procedures, not only do we need to have the support of surgeons, if we're dealing with a surgical issue, to go in and look at surgical charts in a hospital, but in many instances, to make the most sense of a procedure from a clinical standpoint, you may also need access to office charts. So it's very important that we have an atmosphere of cooperation and that this be handled with due caution and respect for the stakeholders.

Longer term, we've raised the issue of whether there might be some broad coordinating function developed, and that's outlined in chapter 9 of the atlas. I won't revisit that here. I would simply say that the atlas really is, as you've suggested, a first step. We see the small area variations as screening tests and nothing more.

Mrs Sullivan: You've raised in those remarks a third question that I'll just put very quickly. To enable access to the office charts that may assist you in further investigation, will you need legislative change with regard to patient records?

Dr Naylor: I would really want to give that a great deal more thought before speaking to it. It's clear that there are a number of major issues for all the self-regulatory bodies around the question of access to patient records in respect of quality management. These issues touch on very cogent concerns to the public of privacy and confidentiality.

The institute's own work is safeguarded by a research ethics board, and again, we're very wary of those legitimate concerns of patients as our stakeholders of last resort, really, about potential violation of privacy and confidentiality. I would really want to take a lot more time to consider any proposal around legislation before making a comment at this time.

Mrs Sullivan: Another question is, with the shift in the hospital operations to increasing emphasis on day surgery and ambulatory care, are the databases and the sources that you've used to draw your first conclusions in fact going to be reliable as that change occurs in the future? Can you capture day surgery through your current data?

Dr Naylor: Yes, we can. There are some very interesting analytical issues, though, raised by that question. Day surgery data are really quite comprehensively tabulated for a whole variety of procedures now. Some diagnostic procedures are not tabulated; for example, outpatient coronary angiography, to give an example, has been inconsistently captured, and there will always be an area where we have to continue to press for more complete data captured on the diagnostic procedural side. However, surgical procedures is one example that tends to be very consistently captured.

One of the issues, however, is what the definition of day surgery is. For example, individuals may stay a couple of hours or less for a procedure, or they may stay 23 hours. What constitutes a day? Accordingly, you'll notice that in the atlas we've taken a fairly cautious analytical position. When we have analysed day surgery, we have combined that with total length of stay data for each surgical procedure, and each day surgery procedure is being attributed as a half-day stay.

The net result is to create an omnibus analysis that combines not only the day surgery procedure as a potential cost to the hospital but the actual length of stay when the procedure is done in the same hospital on an inpatient basis. It's an approximation, to be sure, but I think it's a cautious one and the best one we can have at present.

Mrs Sullivan: There's not a lot of data available from community-based care delivery on the treatment-therapeutic side. Certainly, it's not included in this particular atlas. Is it appropriate from your point of view that some kind of mechanisms be started to in fact do this kind of analysis on the community-based, home-based, hospital-in-the-home approaches that are becoming more and more prevalent?

Dr Naylor: We'd be very interested in trying to access community service data and to link it as appropriate to HMRI, OHIP and other data sources. This is under way to some extent in Manitoba. One of the focuses of the Manitoba Centre for Health Policy and Evaluation is to try to get a better handle on community and social service integration with health services. We're impressed with that work and we'd like to emulate it to some extent here.

Again, there are major issues to be worked out with information and planning within the ministry about identifiers, the extent of those databases, accessing them, and a lot of background work is necessary.

More generally, one of the issues for us, of course, becomes priority-setting and analysis. We have a strong clinical orientation. We have to be a little bit unapologetic about that because of our cosponsorship. There are many other research groups in the province that I think would share an interest in analysing data on health and social service integration. For example, there's a health system research unit at McMaster. Its particular focus, under the leadership of Dr Gina Browne, is on health and social service integration. I'm certain they would be very keen to collaborate with us on that kind of work.

Mrs Sullivan: I think that the question of the sponsorship of ICES itself is a matter of interest. My personal view is that a more independent sponsorship might be more valuable in terms of a suspicion with respect to the biases or perceived biases of the organization. Would you like to comment on that?

Dr Naylor: I would simply say that the question is obviously a very difficult one for me. I sit here as a physician with a major interest in clinical issues personally. Many of my colleagues in the institute, be they physicians or PhD epidemiologists, share those clinical interests. We're interested and see the physicians as very important stakeholders and we value the ongoing collaborative relationship with the Ontario Medical Association. Beyond that, I think that comment by me would be perhaps injudicious.

Hon Mrs Grier: If I could just expand on that comment, I would perhaps take issue with the member's comment about the independence. I have every confidence in the integrity of the work and the independence of the scientists who are working at ICES, but I do share the recommendation as part of the practice atlas that we need to look at a more broad stakeholders' committee, council or whatever that would enable us to integrate the kind of work that's being done by ICES with, for example, the work being done by Cheppa at McMaster and others are doing similar work, and bring to bear on the issues the advice and the point of view of other stakeholders.

As we work through the JMC with the future and the implementation and the work to deal with the recommendations and the findings of the practice atlas, the broadening of that base will be something we'll be looking at with interest.

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Mrs Sullivan: Some of the strategic recommendations in chapter 9 are in fact as interesting to people at Queen's Park as any other part of the atlas is. You have recommended a number of vehicles, not the least of which is a regional funding and delivery, with options for more regional participation in strategic and ongoing planning. I don't think that's the first time that recommendation has come forward. I think I recall a speech maybe a year ago that made very similar recommendations.

Another recommendation that I think is quite appealing is for the Ontario health services council. Certainly what I see in the entire health field is enormous compartmentalization and fragmentation and very little sense of common goals. I wonder if you just wanted to expand on that recommendation.

Dr Naylor: Let me start on the regionalization issue. The wording of the atlas I think is very cautious, and with good reason. We notice that there is a trend to increasing adoption of regionalization in a variety of provinces, but what we suggest is that if there is to be a move in any way towards regionalization, it has to be regarded as an experiment on its own and to be evaluated as such. We certainly urge very careful study of the experience with decentralized management in other jurisdictions. I would include the United Kingdom in that respect.

I would also highlight, in keeping with the comments of the minister about the independence of the institute, that I sit here as CEO of the institute but also as a scientist among scientists, and that there is an enormous diversity of opinion among my colleagues about decentralization. I can find within our scientist group individuals who are ardent exponents of decentralization and others who are extremely concerned about the potential compartmentalization on regional lines that might occur with decentralization. I have to confess that, as always, dealing with scientists is a bit like herding cats. There is no consensus and there is ample disagreement on policy issues as opposed to issues of clear science.

Beyond that, dealing with the health services council, we have advocated that as an umbrella body. There is, in that respect, a clear consensus among the scientists at the institute and indeed a great many of our senior staff.

We are well aware, however, that there is a danger in any such body that it may become another layer of bureaucracy or it may become an irrelevant paper factory. We're keenly aware that there's very little room for additional funding of any such bodies in the current climate of funding, that the priority has to be providing services as best we can.

We made the case, I think, in the most low-key way possible about some of the advantages, really leaving this as a trial balloon for those within the Legislature and within the ministry to consider. We believe it would be beneficial. We think it could be done with a small investment. We would be happy to work with such a council but, beyond that, we really see this as something to be debated by policymakers.

Mrs Sullivan: Thank you very much. I'd like to turn to a few more mundane and less esoteric --

The Acting Chair (Mr Wayne Lessard): Are those all the questions that you have for Dr Naylor?

Mrs Sullivan: Yes, that's all I have for Dr Naylor.

The Acting Chair: Mr Wilson, do you think that you'll have any questions for Dr Naylor?

Mr Jim Wilson (Simcoe West): Not at this time.

The Acting Chair: Would it be okay if he leaves for the rest of the day if none of the other committee members have questions? Thank you, Dr Naylor.

Mrs Sullivan: I'd like to return to a question that I raised in the introduction to the estimates with respect to the Regulated Health Professions Act and the proposals by the dental hygienists for changes to legislation.

I asked why in particular the minister had agreed to consider proposed legislative changes to the Dental Hygiene Act, using a ministerial route rather than Health Professions Regulatory Advisory Council, and the minister indicated that in fact that consideration would not be for legislation at this time, ie, in this session, or perhaps not in the next session.

I guess I want, first of all, an assurance that the HPRAC process will be used for changes to the legislation, that there won't be shortcutting through a ministerial route. Secondly, the minister indicated as follows, and this is a quote from the transcript:

"But I know the concern of the dental hygienists and am happy to be able to tell the committee that, as an interim measure, the College of Dental Hygienists of Ontario and the Royal College of Dental Surgeons of Ontario have come to an agreement which allows dentists to issue a general, rather than a case-by-case, specific order for most procedures."

In fact, that's incorrect. The college was asked to accept an agreement which provided a general order. The college indicated that its legal advisers had given them an opinion that such a move would be illegal and in fact contrary to its own regulated act. I'd just like some clarity on this issue.

Hon Mrs Grier: I regret if the statement that I made was incorrect. It was certainly my best information at the time, and I'm not sure that I can give any more advice at this point. I will certainly follow up on that and be sure that when we come back on Tuesday, we have whatever information is required.

Mrs Sullivan: Good. Thank you.

Hon Mrs Grier: Can I deal with the HPRAC issue, though, or are you going to raise that again? I think it's important to be clear that the Health Professions Regulatory Advisory Council is an advisory council to the minister, so matters are referred to it by the minister. That does not necessarily mean that every issue dealing with the Regulated Health Professions Act is necessarily advised to HPRAC.

For example, on some of the regulations in the initial stages we had extensive discussions with HPRAC as they were the first time that regulations had been developed. Once the templates had been established and we moved into all of the other professions, then the regulations were not referred to HPRAC. So it is entirely at the minister's discretion when issues are referred and the directions given in that referral.

Let me make a comparison that the member will be familiar with. I don't know which piece of legislation it is, but certainly when I was Minister of the Environment, there was the Environmental Assessment Advisory Committee, which was frequently very valuable to the minister as a source of advice and as a means by which the public could be consulted on an issue of public interest. But not every request for an environmental assessment was necessarily referred to the Environmental Assessment Advisory Committee for advice, and I see the relationship and the incredible value of HPRAC as being somewhat analogous.

Mrs Sullivan: Minister, my understanding is that in fact the statutory requirement is quite different in this scenario, and indeed there are very, very strong concerns among the professions that the approach that is being taken with respect to ministerial action or decision-making without referral to HPRAC is against the law. I just don't happen to have, in all this mad pile of papers here, the particular section and the particular act.

However, I do think that it's a matter that should be looked at quite seriously, because the dental hygienists and the college of dentistry are not the first instance where the issue has been raised. It has been brought forward by other professional bodies, and there is deep concern about the short-circuiting of what people believe to be and see as a statutory provision for consideration by HPRAC on the major issues associated with the legislation and regulations.

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Hon Mrs Grier: I think the member in her concluding sentence outlined precisely what the dilemma might well be, referral to HPRAC on the major issues, and then we're into some definition as to, does this reflect a major change in direction or is this in fact implementation and in conformity with the act?

For example, if there is an issue upon which there is general consensus within the profession, is the member suggesting that therefore must be referred to HPRAC even though there is general agreement among all of the stakeholders that the action that's been proposed, including agreement with the minister, is the advisable one? It would seem to me that would be just an additional layer of bureaucracy that I'm sure nobody would want to impose.

On the other hand, obviously when there is something as contentious as -- incorporation of physicians is perhaps one example, and the excellent work that HPRAC did with respect to Bill 100. Those are issues that, without HPRAC's advice, it would be very difficult to move forward. I think as the legislation is implemented, we will all gain experience with it as it goes through the process, but I certainly consider HPRAC an extremely valuable source of advice, information and forum for public discussion of issues of public interest.

Mrs Sullivan: I would like to see some kind of a legal opinion from the ministry with respect to the statutory obligations and the relationship between the minister and HPRAC. I think other people who brought the issue to my attention would like to see that as well.

In an order paper question that I put to you -- I'm not certain when, but it was probably in March -- I asked about, first of all, the operations of the Hospital Training and Adjustment Panel, costs and how many hospital workers were placed and assisted and so on, a full accounting of the HTAP program, because certainly as HSTAP is coming to the fore, I think the matters are of continuing interest, particularly when there is considerable downsizing among the hospital sector and in other health sectors and a trend perhaps to more generic workers in some fields.

I was very interested in the response which I thought was remarkable in its lack of clarity, and I'm sure that was deliberate. What we saw here was a budget of $30 million under the initial HTAP project; what appears to be about $2 million of that funding spent for career counselling and résumé writing services for 1,100 people; 2,200 people who had completed a needs assessment but only half of them went on to anything else, and then a certain smaller number went on to the second tier. So $2 million was spent in the actual work associated with the assessment and counselling work.

However, it appears that the overhead in providing that amount of service to a significantly smaller number of people than the total number who were displaced in the 1992-94 period, the administrative costs were three times that. My understanding, although it's certainly not included in the evaluation report, is that in fact there were only 17 people placed for all that money that was spent. So I think there are legitimate questions with respect to what occurred in the past -- I know that the evaluation report was done -- but in fact what will take place as HTAP comes into place.

We certainly know about the $22 million that has been promised to go back into the system in Windsor. We understand that those promises included that displaced hospital workers would maintain seniority, salary and benefits if they moved into the community sector. Certainly that is the understanding on the ground in Windsor.

If that's not the case, I think that should be made very clear at this time, because community agencies across the province are looking with deep, deep fright, purchasers are looking with deep, deep fright at the cost implications of that kind of a guarantee, basically a job guarantee for ever within a system, or at least not a particular job guarantee but certainly a work guarantee at the same level of salary, benefits and seniority.

I think that you can understand why some municipalities, by example, as they're looking at their contributions to homes for the aged, are aghast, why community agencies are aghast if that kind of a promise is being made. I would like a full clarification of what guarantees have been made to workers as restructuring and movement occurs in the Windsor restructuring, because that will become the template for the province.

The Acting Chair: The answer to that should be in three minutes or less.

Hon Mrs Grier: Let me respond first of all by talking about Windsor, because I don't quite know where the member gets her information from. She certainly is adept at setting up a straw man or straw woman and giving us an opportunity to say, "Well, that's not what's happening."

Certainly, as the Windsor restructuring occurs, human resource planning is going to be an absolutely critical and integral part of the changes. I think I indicated that. But the terms under which that occurs and the way in which it's done are what in fact the Windsor DHC or the implementation committee and the executive director are now doing.

Mrs Sullivan: Excuse me, Mr Chairman, I have one more question, but I would like to see in writing the full detail of what promises have been made and what commitments have been made in the Windsor situation with respect to human resources restructuring.

Hon Mrs Grier: There is absolutely no such paper to provide the member with.

Mrs Sullivan: Could one be prepared then?

Hon Mrs Grier: If I haven't made a promise in writing, are you suggesting I make one and give you a copy?

Mrs Sullivan: I would like to know what the government policy is with respect to this issue, because certainly the expectation and the belief among the Windsor workers are that those promises have been made.

Hon Mrs Grier: Let me not treat what is an absolutely important matter lightly. I had extensive discussions with the Ontario Federation of Labour, with the health unions within the Ontario Federation of Labour and with the labour adjustment committee in Windsor-Essex and a number of other restructurings. I certainly know the worry and the fear that workers in this province have about restructuring and about changes within the health care system, and that the kind of employment security agreement the member is describing is something that they would very much like to have.

It has not been something to which I have been able to commit the ministry or the government at this point. But as I've said on a number of occasions, publicly and here, human resource planning is critical. Providing the opportunity for people who are working in institutions to get the training, to get the counselling, to get the help that they need in order to make them both aware of opportunities in other parts of the system and ready to take advantage of those opportunities is something that we are asking all the district health councils in their human resource planning to do in a general way, and hospitals, with respect to restructuring, to factor into their work.

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For the member to suggest that if there isn't a promise this isn't happening would be misleading. I hope she's not doing that. Of course it is, particularly for our government, a very high priority, working to make sure that as more jobs open up -- and as I've said in long-term care on many occasions there will in fact be more jobs than there are now -- certainly our commitment is that any displaced workers should have access to new jobs that are created in the community and that we have to find ways of doing that while acknowledging that there is currently an enormous imbalance between the benefits and the seniority and the security in institutions and in many community-based agencies.

That's why I'm so proud that our government, even in tough times, has moved forward with pay equity so that we can make, and have made, significant moves in increasing the standard of wages for, particularly, women employees in long-term care and in voluntary organizations. It is the fulfilment of those kinds of commitments that makes it possible for us to talk realistically about the kind of labour adjustment that's needed as the shift in health care occurs, unlike in other provinces, Nova Scotia, Newfoundland and Alberta being the examples, where you're seeing massive layoffs without the safety net being put in place to make sure that restructuring is not done on the backs of the workers.

Mr Jim Wilson: Mr Chairman, I think, due to the length of that answer, Mrs Sullivan deserves one short question that she's dying to ask at the moment.

The Acting Chair: You're agreeing to let her use up the first part of your time to do that?

Mr Jim Wilson: Yes, she can have three minutes.

Mrs Sullivan: We'll subtract our time from Tuesday, if you want. I want to know, because the minister has raised the London teaching hospitals' recommendation for reconfiguring that has been approved by the Thames Valley DHC, if the minister is prepared to go ahead with an acceptance of the proposal and if the minister is prepared to bring the particular amendment to the Public Hospitals Act forward that will enable that new funding vehicle to be put into place to ensure that that reconfiguration can proceed.

Hon Mrs Grier: I think the member is jumping several steps ahead of where the institutions in London are in fact at with respect to their discussions on restructuring. As the committee knows, I was there yesterday, which is why I was late here, meeting with both the Thames Valley District Health Council and representatives of the hospitals.

I think after a lot of discussion some very creative work has been done and a breakthrough has been achieved in the agreements on a governance structure for the institutions. That is an initial step. There would be a lot more work to be done and a lot more work to be done with the broader community before there was any reconfiguration of the system or recommendations as to how that ought to be done.

We have accepted with interest the proposal on governance, and I'm glad to be able to tell the member that while we are considering the implications of that and how that might, if it was appropriate, be achieved, we have -- and yesterday I was able to confirm this with the DHC -- accepted a proposal that there be a committee structured under the chairmanship of a representative of the DHC to work on the next stages of preparing for a reconfiguration, that kind of restructuring study and work to be done. I was able yesterday to say to the DHC that we had approved $100,000 in funding for that planning to begin.

I think there are some very encouraging initial steps that have been taken among all the hospitals in London. There is more work to be done and a great deal of community consultation that will have to occur before we are into the kind of system-wide reconfiguration that the member refers to.

But having heard from the Healthy Communities Coalition and the work that the hospitals are doing in networking and creating partnerships with community-based organizations, I was, as I've said, very encouraged by their openness to looking at the entire system and not merely at the teaching hospitals in isolation from the rest of the system. I look forward to being able to allowing that and facilitating that to continue.

Mrs Sullivan: Thank you, and thank you for the time, to Mr Wilson.

Mr Jim Wilson: You're welcome. Minister, I just want to go back to Windsor and Essex county again and ask, if you could, for just a very brief status report. I don't have it with me, but I remember reading the letter that was cosigned by the hospital administrators, CEOs and the Windsor-Essex county medical society that talked about their concerns about adding another layer of bureaucracy and cost in that restructuring. What was the ministry's response to that and what is the status specifically of that governance issue?

Hon Mrs Grier: A lot has happened since that particular letter was signed and I accepted the recommendations from the reconfiguration proposal. The implementation committee has been put in place. Mr Hume Martin, as you heard in an earlier question, has been appointed as CEO, and in fact I think a number of the concerns that were raised before people had an opportunity to read the report from the steering committee and from the DHC have, I hope, been allayed. But I could ask the assistant deputy minister, Mr Rochon, who was in -- "daily" would be saying too much -- certainly weekly contact with that implementation committee to bring you up to date on the status.

Mr Jim Wilson: I'd appreciate that.

The Chair: Mr Rochon, you've been introduced already and you've been present for the question. Please proceed.

Mr Rochon: Two components of the reconfiguration report include the mergers of four facilities into two in Windsor. One is the Hotel Dieu-Grace alliance. As you know, the Hotel Dieu is owned by the Sisters of St Joseph and the Grace is owned by the Salvation Army of Canada and Bermuda. In trying to deal with the merger or alliance of those two organizations, the organizations had to go and talk to them about significant bylaw changes at "head office" with two separate owners outside of the community.

It was a rather complicated matter for them, but I'm pleased to report to this committee that the two corporations -- the Sisters of St Joseph and the Salvation Army -- submitted to the Ministry of Health bylaw amendments that deal with the formation of the alliance in Windsor. With the authority the minister has delegated to me to approve bylaws, we signed off on the approval, forming the alliance.

Mr Jim Wilson: Can you just tell me what the alliance structure is now?

Mr Rochon: Yes. The alliance structure is one whereby in effect the operation of the Grace hospital will be undertaken by the Hotel Dieu. The Hotel Dieu sort of management structure will operate both sites, and the governance structure provides for membership from the two organizations. That's under way and it was approved approximately two to three weeks ago and they've been meeting since then. It took a long time to get to that point, many months and years of discussion.

The second merger involves Windsor Western and the Metropolitan General Hospital. Both organizations have committed to the merger concept. They feel very strongly that it's in the best interests of their community and they feel that the public interests would best be served if they merged.

They are going through discussions right now about what merger means in terms of governance, bylaw and operating a corporate structure, so they're not as far along as the Grace-Dieu alliance. But, based on the information I have, they're continuing to move in the right direction.

Mr Jim Wilson: In bringing me up to date here, you've ruled out the concerns that were expressed in that letter that I was referring to of an overall governance structure that would be costly and --

Hon Mrs Grier: It was never part of the plan.

Mr Jim Wilson: When six people sign a letter, I don't say it was never part of the plan. I don't assume they're crazy, Minister, and they make these things up.

Hon Mrs Grier: They hadn't seen the reconfiguration report and they hadn't heard the response of the ministry to the recommendations when that letter was signed. I think the fears that were raised, as so often happens, were being raised unnecessarily and I hope the answers you've had will allay those who still share them.

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Mr Jim Wilson: I want to move on to dental hygienists and dentists. Minister, we had an opportunity to speak briefly about this issue a couple of weeks ago in the Legislature. So that all members know, dental hygienists have been expressing some concern recently that with some of the content of the RHPA, because they're under order of a dentist, that may affect some of their ability to treat patients under the guise of the public health sector, and there's a bit of a controversy brewing there.

I just want to clarify really for the record, you indicated to me that when the rumour was circulating that Allen Burrows was drafting amendments to the RHPA to deal with this issue, that rumour wasn't true and you were taking steps to ensure that all parties concerned were aware of what the ministry's intentions were and that your intentions weren't to open up the RHPA during this term of office. Could you just comment on that for the record?

Hon Mrs Grier: Yes, I'd like to, because I don't know whether you heard Mrs Sullivan's question. I have certainly assured her that I understood agreement had been reached with the college and that there had been some understanding that a general order could be issued and that some of the worries of the dental hygienists had been allayed. She said this afternoon that her information was that this was in fact not correct, and I've undertaken to get back to her on Tuesday with the most up-to-date information.

Jodey Porter, who's the assistant deputy minister who dealt with the Regulated Health Professions Act, is here, and I think, seeing that the issue has been raised again, if she could shed any additional light or give some background and explanation to this issue, that might be helpful.

Mr Jim Wilson: Could I just say, I listened carefully to your response to Ms Sullivan's question about this. You weren't as clear in your response today as you were to me in our private conversation, so I'm giving you the opportunity to clarify this. If the government is saying it's not going to open up RHPA within this term of office, then that's something that should be stated for the record.

Hon Mrs Grier: That was what I had stated on the record here a couple of days ago, that I did not see at this point opening up the RHPA, certainly in this session, perhaps not in the next one, that as we learned how to deal with the RHPA and as the professions became more familiar with it, there might well be a package of changes required to be made at some future date, but that I thought it would be inappropriate to -- every time an issue is identified, then we'd have to go through legislation again.

I think we have to live with the legislation for a while, understand what mechanisms we have to deal with some of the issues that arrive, and if it comes to the point where additional legislation is required, obviously we would look at that, but I'm not sure we're there yet. Perhaps Ms Porter can expand on that.

The Chair: Ms Porter, you've been suitably introduced for Hansard purposes. Please respond.

Ms Jodey Porter: If I could just get some guidance from you, Minister, and from the Chair, is it your wish that I also deal with Ms Sullivan's questions?

Hon Mrs Grier: I think if you can --

Mr Jim Wilson: No, please just give us the status of this particular one.

The Chair: Could I just say that I really try and do this in an informal way because I think it's very helpful, but there are certain rules we have to follow. I think if you direct your response to Mr Wilson's questions, he is actually asking you questions through the Chair. An opportunity will occur for Ms Sullivan either today or another day, or you can get back to her separately. This is Mr Wilson's half-hour of time and he has the responsibility to order it up as he sees fit. If he wants to yield more time, that's fine.

Ms Porter: Basically. we feel what is happening is that we have been approached on a number of fronts by various colleges and various professional groups in terms of conflicts relative to scope of practice across a broad range of issues. The dental hygienist issue and the optometry-ophthalmology issue are two in a long series of conflicts, in terms of health policy as it is presented, that we need to resolve in terms of relative scope of practice.

The ministry indeed, and Mr Burrows, is not drafting amendments or drafting legislation at this time. What we have undertaken to do and what we have done formally and publicly is send out letters, as of the middle of March, to all the involved stakeholder groups, including both colleges directly involved as well as the Ontario Dental Association and other stakeholders, to say that we were receiving briefs and submissions on the issue of scope of practice for dental hygienists, that we did undertake to begin and launch a public consultation process.

We had a consultation including the stakeholders on May 25. At that time the Royal College of Dental Surgeons, although they had submitted a brief to us, in fact decided not to formally introduce the brief through a public consultation process. They did comment that they disagreed at that stage with a ministry process and preferred an HPRAC-driven process to ensue.

At this stage we are still in the consultation mode, listening to both colleges, receiving information, and frankly will not be ready to take recommendations to the minister for some weeks.

Mr Jim Wilson: I'm well aware of the Royal College's desire to send this to HPRAC, and I'm a little dismayed that it wasn't sent to HPRAC by this point. That's still an option available, is it?

Ms Porter: It's our understanding in terms of RHPA that the minister does have broad discretionary powers in terms of referral, depending on the level of public interest, the level of health protection and considerations in terms of relevance of a review process, between an arm's length body like HPRAC, which is far more of a Solomon and out there to deal with quite complex public policy issues as well as health policy issues, and frankly what can be reviewed and analysed by a ministry bureaucracy that has been in this business for just over a decade. Those discretionary powers are there, and we have followed this route on this occasion.

Mr Jim Wilson: Mr Chairman, while Ms Porter is with us, I'll ask the minister -- perhaps Ms Porter would like to comment on it, though -- you did mention the issue also that surfaced with respect to optometrists and the prescribed diseases list issue. Do you want to let us know where that is and where the ministry's heading? It's another matter that I know there's been a request that it be sent to HPRAC.

Hon Mrs Grier: Yes, I'm well aware of that, and it is under active advisement.

Mr Jim Wilson: What exactly would that mean? I have a letter, for the record here, from Dr Peter Rozanec that I think was sent to all members of provincial Parliament, dated May 30. He is an optometrist from Port Credit. I also have a letter from Dr Mira Acs, who's president of the Ontario Association of Optometrists. Other than being under active consideration, surely to goodness, Minister, you have more to say than that.

Hon Mrs Grier: What that indicates is that I'm well aware of the issue, have certainly received correspondence on it and at this point it is still under consideration whether or not it be referred to HPRAC and, if so, what form the recommendation would take.

My deputy tells me that in fact a referral has been made. I didn't know whether it had in fact gone out. I was being coy, because I knew I had made the decision to do that and wasn't sure whether in fact HPRAC had been informed and whether the letter had gone. Let me then be very clear --

Mr Jim Wilson: I'm glad we have these sessions, Minister, to bring you up to speed on your own decisions. It's very helpful.

Hon Mrs Grier: What happens -- let me explain -- and I do find it discombobulating on occasion, is that the time between a decision being made by the minister and the paperwork being done and the letter being signed and transmitted is sometimes at least a week. So I go out and tell people I've made a decision and they have not been formally advised and then everybody gets very upset with me and with the officials. I try not to allow that to happen --

Mr Jim Wilson: Your life history's very interesting, but --

Hon Mrs Grier: -- because I have some excellent officials who serve me very well. I've asked them to give me the date when they expect they might have an interim report but, in any case, I have asked them to give me their advice by December 31, 1994, so that is under way.

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Mr Jim Wilson: Minister, I am requesting a list of all matters that have been referred to HRPAC and their status. Is that something that's easily enough done by the ministry?

Hon Mrs Grier: Very easily.

Mr Jim Wilson: Okay. Because I think it's quite important. As everyone is aware I think, there are a number of issues brewing, and it would be very helpful to have a sort of list we can refer to on what actually is at the advisory committee and what isn't.

Hon Mrs Grier: Let me just say that the number of regulations under RHPA was phenomenal. I think there were 120 regulations. The branch of the ministry prepared those regulations and had them through leg and regs committee of cabinet and cabinet and with HPRAC's advice on a number of them in a period of three months. It was an extraordinary amount of work, and I think put a real burden on HPRAC, so that while all of that was happening they were not asked to advise me on other issues.

It has been since the proclamation of RHPA and the template regulations were in place that they have been free to advise on more general matters and of course the issue of the incorporation of physicians, which was referred to them as part of our agreement with the OMA and was another major piece of work that we asked them to do very quickly. So they have had their hands full, and we are now looking at some other referrals to them such as the one under the Optometry Act that I just referred to.

Mr Jim Wilson: Minister, will it be possible to get a copy of the letter regarding the optometry matter that you've indicated you've sent or are sending?

Hon Mrs Grier: I will certainly bring an update on the status of referrals and the nature of those to the committee.

Mr Jim Wilson: The letter was addressed to all MPPs so I assume that you would have responded to that May 30 letter.

Hon Mrs Grier: So you knew I'd sent it when I didn't know I'd sent it.

Mr Jim Wilson: I had a pretty good idea you'd sent it.

Hon Mrs Grier: I see. Okay. That's the kind of critic I am familiar with.

Mr Jim Wilson: It took 10 minutes of my time to get you to realize that.

Hon Mrs Grier: If you'd just been up front and said, "I have here the letter that you've sent to HPRAC," you might have saved us all 10 minutes.

Mr Jim Wilson: I don't have 100% confidence in my sources, Minister, so I take these things with caution.

Hon Mrs Grier: If it's signed by me, it's a pretty good source.

Mr Jim Wilson: Mr Rochon did provide me yesterday, pursuant to my request, a list of capital projects, their status and what will be paid out in 1994-95. I was wondering, Minister, I'd just like to ask a specific update in writing from the ministry on the Simcoe county hospital redevelopment projects, the status of those projects. I now have the dollar figures that are to flow in this fiscal year, but I would like a brief paragraph on the status of each of those projects if that's possible.

Hon Mrs Grier: I'd be more than happy to ask my deputy to do that.

Mr Jim Wilson: I know my colleague Mr David Tilson from Orangeville is very much wondering about the status of the new hospital in Dufferin county. There are many, many others, but those are the ones that I would ask for at this time.

Mrs Mottershead: There certainly is an indication here on pages 2 and 3 for the three hospitals that you were concerned about, and there's some cash flow indicated that I think is positive reinforcement of the government's intention to proceed.

Mr Jim Wilson: I agree, Deputy, to the extent that I guess the cash flow is a relatively small amount of dollars compared to total project cost and most of it is study money. You can't reiterate often enough the fact that these promises for the hospitals -- I've just mentioned Dufferin and Simcoe -- go back almost a decade, over three governments now, so the communities are getting pretty tired of studying these issues to death.

I just want to move along to -- where did the minister go?

The Chair: Proceed with your question.

Mr Jim Wilson: Perhaps I'll skip what I was just going to do and ask the deputy to provide the total cost of the consent-to-treatment legislation, its implementation to date. I notice in the estimates books that there are line items for that specific piece of legislation. It's an incredible amount of money, as it appears in different places throughout the estimates book, and I'd like to know what the total cost is and what the status of the implementation of the legislation is. Do you have any comment on that now, Deputy?

Mrs Mottershead: I can let the member know that we are working on the implementation together with two other ministries, in particular the Ministry of the Attorney General and the public trustee's wing of that particular organization. We are moving ahead. We are preparing some public information material over the next two months, which will be available, that describes the issue of substitute decision-making, as well as the kind of tool that we're trying to find to make sure there is consistency in how the decisions are made.

Work is progressing. It appears like it's a large amount of money when you look at the estimates in the book, but a lot of it is for purposes of education and information. We're hoping, through the medicine and law institute, to put on a few educational sessions so that people understand all three pieces of legislation and know how to proceed when faced with that kind of situation.

Mr Jim Wilson: Our Consent to Treatment Act is specifically Ministry of Health. I'm wondering if you can provide the same type of information or get it from the other lead ministries for the Advocacy Act and the status of the Advocacy Commission. Is that possible for you?

Mrs Mottershead: That's certainly possible.

Mr Jim Wilson: Because the public sees these bills very much together.

Mrs Mottershead: I'm sure if one looked at the estimates of the other two ministries, you definitely would see there is government commitment in the form of additional dollars provided for the Advocacy Commission, and certainly in the Attorney General's ministry in terms of substitute decision-making. I'm sure that information is probably in here. If it's not available in here, then we can undertake to ask those two ministries to provide that and put it together with ours in terms of a plan for the expenditure.

Mr Jim Wilson: As you know, yes, there are some figures available for advocacy in the estimates book. However, again, it doesn't give you any status report on the implementation of that legislation. I don't know if your ministry can find it or not. If you can, I'd appreciate it.

Mrs Mottershead: We can certainly do a general note that covers the status of those three initiatives and where they are, because you will see a lot of activity over the next couple of months in terms of public education --

Mr Jim Wilson: Don't rush.

Mrs Mottershead: -- in preparation for proclamation later on in the year or early next year.

Mr Jim Wilson: I also want to ask, and I might as well ask the deputy this since the minister isn't here at the moment -- oh, here she comes. It's very difficult to obtain from estimates exactly how many people work for the Ministry of Health. I would be quite interested to know the actual employee numbers both in the minister's office and in all the branches of the ministry over the past 10 years, if that can be provided.

Mrs Mottershead: Ten years?

The Chair: It certainly wouldn't be ready by 6 o'clock.

Mr Jim Wilson: I actually asked for it last year and the year before and I never did get it.

The Chair: First of all, let me just indicate that from the current estimates book, it's an obligation for the minister to bring those numbers forward within the time frame of the estimates. That's clear. However, the amount of work that goes into that, it would have to be treated much like an order paper question and they would undertake to get back to us with it. Certainly if you're formally requesting that breakdown, that can be ready by next Tuesday, because it's an immediate matter from the current estimates.

Mr Jim Wilson: Mrs Sullivan makes a very good point. The availability of employee numbers, person-years, used to be quite easy to find in the budgets, for example, and in the last few years it seems to me these things have dropped right out. We have dollar figures.

Mrs Mottershead: You have that information in the budget. It does talk to the number of government employees and it does break it down by ministry. It is in the Ontario budget. It gives you the phone number. I think the Treasurer in that budget also indicated very specifically the number of positions that have been eliminated through attrition and the plan for next year. There is a number, an OPS-wide number, as well as ministry-specific.

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In addition, that information is available through the Management Board Secretariat, and when those estimates come up they have the aggregate number and the individual ministry number. We do have a ministry number. It would be very difficult, I must say, to pull that information over the past 10 years, given that there have been about half a dozen or more reorganizations and realignments and all of that kind of stuff. We wouldn't be preparing branch to branch, and what was then isn't necessarily what is now. However, we'd be pleased to provide current as well as last year so that at least you have a couple of years of information.

Hon Mrs Grier: The addition of long-term care from Comsoc was one example of the kinds of shifts that have occurred, I'm sure, over the last 10 years in a number of directions.

Mr Jim Wilson: Let's leave it this way: provide whatever you can as quickly as you can. I'll let you off the hook on that.

Hon Mrs Grier: A lot of people and they all work very hard.

Mr Jim Wilson: Minister, you wouldn't want me to quote Hansard from the past, when you were on the other side of the fence.

Hon Mrs Grier: I was never Health critic.

Mr Jim Wilson: No, but you were a pretty good critic in a number of other areas as I recall.

I want to raise the issue that was raised again by Mike Harris in the House this afternoon, and that is out-of-country payments or the out-of-country policy. I should say, to begin with, that I think you had agreement of the parties in the Legislature when, I guess it was last year, the government moved forward to cap the out-of-country payments at $400 a day. However, it's no secret that there's quite a controversy now with respect to the further move that your ministry has made, and that is to the $100 a day and $50 a day.

I ask you on what basis you do that, given the oft-quoted section of the Canada Health Act. It seems very clear to me and to the snowbird association and to other parliamentarians that you are against the Canada Health Act. Do you have a legal opinion to suggest that you're not against the Canada Health Act?

Hon Mrs Grier: Let me address this, because I think I certainly understand the concern that the snowbirds have and I think the answer the Treasurer gave in the House today covered the issue, but let me try again.

The Canada Health Act is federal legislation and the decision as to how it should be interpreted lies with the federal government. It has over the years been interpreted in different ways in different provinces, and in some cases the federal government has expressed an opinion about a particular interpretation or activity by a province. In others they have not.

As I'm sure the member knows, we looked very carefully at our budget this year as to how we could in fact constrain the increase in costs in health care that had occurred through the 1980s and at the same time provide the opportunities for more efficient management and operation of the system and expansion of the system in those areas where there were growing pressures and needs, whether those be long-term care, cancer treatment, dialysis, which is close to the member's heart, or other programs.

I think we've done that very successfully and I'm very proud of some of the innovations we've been able to put forward, but to do that we had to look at everything we were doing and say, "Can we make some changes there that enable us to save some money?"

When I made the choice as to where I could save some funding, to save some money by looking at those services that we paid for in foreign countries for which the beneficiaries already had insurance -- because the $400 a day that we paid to hospitals out-of-country, certainly if it was the United States, didn't cover the actual cost of a hospital bed -- certainly not the hospital bed in parts of the US -- and was not in many cases the equivalent of a hospital bed in parts of Ontario. It went some way towards making that, but it meant that individuals already had to have insurance if they were to safely leave Ontario.

As we looked, as I say, at places where we could make some savings in our health care budget, the imposition of a small, additional responsibility on those Ontarians who leave the province and who buy insurance by way of an additional cost for their premiums, seemed to me to be an appropriate tradeoff for some of the other significant changes that we had contemplated, such as copayments on the Ontario drug benefit plan, a plan which isn't covered or relevant at all to the Canada Health Act and where we are the only province that provides 100% of funding.

I made the decision that we would make some cuts in out-of-country payments. When we looked at the pattern across the country, we found that there were other provinces that were paying much less than Ontario had been paying and that there had been no indication that this was in violation of the Canada Health Act.

Let me also remind the member of the fact that because of inconsistencies, of which this is only one, in interpretations of the Canada Health Act by provinces, the deputy ministers established a task force last November to begin to work together to identify inconsistencies and to see if a consensus could be reached as to what in fact those general principles in the Canada Health Act meant in a number of areas.

As I have stated before, and let me say again on the record, if it is determined by all of my colleagues and the federal minister that there is a consistent interpretation of the Canada Health Act with respect to out-of-country payments, then Ontario will conform to that. It is not our intention to violate the Canada Health Act. In fact we are one of the strongest proponents of the Canada Health Act at federal-provincial meetings.

Mr Jim Wilson: Minister, when you moved to limit the payments to $400 per day for hospital stays out of country, that had a significant effect on insurance premiums, particularly that seniors were paying. But when you moved then again to limit to $100 a day, that had a catastrophic effect -- not a small imposition, as you're indicating -- to the point now where it's difficult for me to believe that you're going to save $21 million with this initiative when many of those seniors simply won't be going out of country or going south for the winter.

If they're going to have a heart attack down south or would have had one had they been down there or whatever and had to have been hospitalized, they're now going to be home and the same thing; you're going to get sick whenever God deems you're going to get sick. I don't see how you're going to save $21 million.

So you tell me what studies you have to show, or any proof you have, that you're going to save the $21 million that's contained in the estimates book, given that a vast number of those seniors are telling us now that they won't be leaving the country and that actually your initiative is an insult to them, because it's almost as if you were saying, "Well, these people go down south to get sick," and of course that isn't the case. You tell me how you back up this $21-million figure.

Hon Mrs Grier: Of course we don't believe that people go down south to get sick, and we believe that everybody leaving the country for any period of time for whatever reason ought to have insurance, and the vast majority do.

I don't accept your contention that in fact this is going to have a catastrophic impact on premium increases. Our understanding from discussions with insurers is that it would be in the range of a 10% to 15% increase in premiums.

Mr Jim Wilson: But that's in addition to the premium hikes last year.

Hon Mrs Grier: The premiums vary depending on age, depending on length of stay.

Mr Jim Wilson: They always have, Minister.

Hon Mrs Grier: If you look at them, you will find that in fact the vast majority of people leave for a month, 30 days, or less, and the premiums jump quite a lot if you're staying longer than that. For a stay of less than a month, which is the vast majority of people who travel south, if south is what we're talking about, or to other parts of the world, the premiums are not excessive and will not, I believe, increase enormously as a result of this change.

The saving comes as a result of looking at what was spent in out-of-country payments last year, which was $73 million, and estimating from that the proportion of it that was spent on hospital costs.

Let me remind you that we continue to pay Ontario rates for physician services out of country. The hospital bed is often a smaller component of in fact the total cost to the consumer of out-of-country coverage, so I don't believe that it will have a catastrophic effect.

There is no mechanism or data that indicates whether in fact people who go south make any less use of the health care system than people who don't. I think the vast majority of people who are accustomed to going south make their decision as to whether or not to go on a number of factors, but primarily the exchange rate has far more impact on their decision whether or not to go and for how long to go than does this change in health insurance rates. I am fully confident that our savings will in fact be realized.

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The Chair: Minister, if I might interrupt you, Mr Wilson has agreed to yield one minute for me to ask you a question on that point and, if I may, it has to do with the issue of the insurance regulation.

Given that auto insurance is regulated by your government and therefore rates can be set, that cannot be said about health insurance. Therefore, did you check with the insurers for health insurance in this province to obtain from them assurances in writing or any costing thereof for its impact on the very issue?

It is a clear distinction here, because the consumer is laid bare in this province as it relates to health care. Their automobile is protected by your government but their physical body is not in terms of acquiring affordable health insurance, and that distinction is clear. When this was raised with your predecessor, certain assurances were forthcoming before substantive moves like this were taken, and I wonder if you did a similar act this time around.

Hon Mrs Grier: No, I don't have written assurances or opinions from the insurance companies. Certainly our understanding in our discussions with them was that this would not have a major impact on rates, and I have no evidence from the costings or, again, the reports I have had that in fact there has been the kind of catastrophic increase in rates.

Believe it or not, Mr Chair, I believe the market responds very quickly to these kinds of changes. For example, with respect to our change in eligibility, when we made the change to students' eligibility for OHIP, there were many students who said, "We can't get insurance." The market has responded and there is now insurance available for foreign students studying in this province.

As health insurance and basic insurance is provided without the payment of any premium by residents of Ontario, I think for those people who do choose to voluntarily put themselves in a position where they need to buy insurance, they will shop around and make agreements, as snowbird associations have, to get the best possible insurance.

Let me make two more points on this issue. We have to maintain the health care system here in this province for those people, should they return or should they decide not to go south or out of country in a following year, and very many people who end up in a hospital in a foreign country as a result of an emergency when they are on vacation or travelling on business have as their first preference being returned to Ontario for health care. That has always happened. That will continue to happen. I think it happens because the insurance companies want to get them back, because they don't want to pay the costs.

We have a lot of anecdotal evidence of hospitals in the US extending stays or seeking to do procedures at exorbitant costs because they know people have in fact Ontario insurance. So the insurers themselves see a great advantage in bringing people home as quickly as possible, and it's my responsibility to make sure that those facilities are here for people who don't choose to go south for a holiday and for those people who need the facilities when they return.

Are we adjourning for a vote?

The Chair: No. We are called to the House for a vote with about 27 minutes before we're called to actually vote. I'm in the hands of the committee. If you wish to adjourn and reconvene next Tuesday, we have almost two hours and six minutes remaining. So we can adjourn now, if you wish, or we can take 20 minutes. I'm really asking the government members what they'd like to do.

Mr Fletcher: If we hadn't allowed 45 minutes for one party, we would have had time for other things, but I think it's a good idea to adjourn till Tuesday.

The Chair: If you'd like to debate the time allocation, Mr Fletcher --

Mr Fletcher: I don't want to debate anything with you at this point in the meeting.

The Chair: -- it's your time you're debating it on at the moment.

Mr Fletcher: No, it isn't, because you're asking for direction, and that's what we said, why not adjourn?

The Chair: Then answer the question I asked you, Mr Fletcher.

Mr O'Connor: We'll probably have time for one more rotation Tuesday. Is this what you're suggesting?

The Chair: You have two hours left on Tuesday, and we'll continue the rotation and the time allocation.

Mr O'Connor: Okay. I think we've done a rotation here. When we come back it'll be our rotation. Sounds fair.

The Chair: Fine. I have some committee business, but this does not come off the minister's time. I have to get a motion from the committee. My options were to do it at the beginning or at the end, and I chose to do it at the end, so I didn't hold the staff here in case there's a debate.

If that's the pleasure, we're adjourning the estimates portion of this committee meeting at this time but we are continuing with another item before the committee. If that's understood, then thank you, Minister. We will reconvene Health estimates next Tuesday.

The subcommittee met prior to the commencement of the estimates today, and the subcommittee met to examine the problem that we will not be able to complete even a small portion of our estimates because of the late start and because we have chosen not to sit till midnight for this two-week period.

The subcommittee has a motion to present to this committee that the Chair request, through the House leaders, a full week in the preferred month of September to complete the third --

Mr O'Connor: The preferred month of September?

The Chair: I'm sorry, in the month of September, thank you -- to complete the balance of the estimates of the Ministry of Transportation, the Ministry of Community and Social Services, Northern Development and Mines and hopefully as well Management Board Secretariat. Is there any discussion on that motion?

All those in favour? Opposed, if any? That's carried.

This meeting stands adjourned.

The committee adjourned at 1738.