Thursday 28 November 1991

Pre-budget consultations

Ontario Teachers' Federation

Ontario Secondary School Teachers' Federation

Federation of Women Teachers' Associations of Ontario

Ontario English Catholic Teachers' Association

Ontario Public School Teachers' Federation

Ontario Hospital Association; Registered Nurses' Association of Ontario; Ontario Public Health Association


Chair: Akande, Zanana L. (St Andrew St Patrick NDP)

Vice-Chair: Sutherland, Kimble (Oxford NDP)

Christopherson, David (Hamilton Centre NDP)

Jamison, Norm (Norfolk NDP)

Kwinter, Monte (Wilson Heights L)

Mahoney, Steven W. (Mississauga West L)

Phillips, Gerry (Scarborough-Agincourt L)

Sterling, Norman W. (Carleton PC)

Stockwell, Chris (Etobicoke West PC)

Ward, Brad (Brantford NDP)

Ward, Margery (Don Mills NDP)

Wiseman, Jim (Durham West NDP)


Sullivan, Barbara (Halton Centre L) for Mr Kwinter

Wilson, Jim (Simcoe West PC) for Mr Stockwell

Also taking part: Lessard, Wayne (Windsor-Walkerville NDP)

Clerk: Decker, Todd


Anderson, Anne, Research Officer, Legislative Research Service

Campbell, Elaine, Research Officer, Legislative Research Service

The committee met at 1017 in committee room 1.


The Chair: Mr Sterling is on his way and will be with us in just a moment. This morning we are going to be hearing presentations from the Ontario Teachers' Federation, the Ontario Public School Teachers' Federation, the Ontario Secondary School Teachers' Federation, the Ontario English Catholic Teachers' Association and the Federation of Women Teachers' Associations of Ontario. I want to welcome you all here this morning. It is nice to see so many familiar faces. I should declare that right from the beginning. It is like old home week, and where were you when I needed you?

I understand the order that appears on your agenda is different from the order in which the presentations will be given. The Ontario Teachers' Federation will present first, followed by the Ontario Secondary School Teachers' Federation. The third presentation will be the Federation of Women Teachers' Associations of Ontario, the fourth the Ontario English Catholic Teachers' Association and the fifth the Ontario Public School Teachers' Federation.


Mr Poste: I am Ron Poste, the president of the Ontario Teachers' Federation. I would like to take this opportunity to introduce the presidents of four of our five affiliates who are here to make presentations to the committee this morning: Gene Lewis, the president of the Ontario Public School Teachers' Federation; Susan Owens, the president of the Federation of Women Teachers' Associations of Ontario; Liz Barkley, the president of the Ontario Secondary School Teachers' Federation, and Mike Coté, the president of the Ontario English Catholic Teachers' Association.

OTF welcomes the opportunity to make this submission to the committee this morning as it relates to the 1992 Ontario budget. We are pleased that this consultation is taking place before the level of transfer payments has been established.

As teachers we are very aware of the human and economic cost of the recession. We see the results of this day to day in the children in our classrooms, who in their own way are every bit as much casualties as their parents or older brothers and sisters who are unable to find work. We recognize at the outset that there is a major economic problem in Ontario at this time. Health, social service and social assistance needs are combining to create a financial problem of unprecedented magnitude. We recognize that recovery in Ontario will not be swift, that Ontario does face a massive economic restructuring.

Looking at this from the educational perspective, we would recommend and suggest that the committee resist any attempts to cut back the support of instructional program. It is going to be very difficult for citizens of Ontario to compete in the global environment of the future. A literate, educated workforce is the province's greatest asset and the key to economic regeneration.

In my reading of the last little while, I did read an article by the CEO of the Magna corporation, who indicated that even in the apprenticeship programs now the demand is for an educated workforce. No longer can apprenticeship programs pick up the type of student they have accommodated in the past. Judith Maxwell, the chair of the Economic Council of Canada, made much the same type of remark. We are looking to a very different type of person if Ontario is to be successful in the future. Without a strong public education system, we believe it will be difficult for Ontario to achieve that objective.

You have heard a great deal about our concern about the decrease in the level of funding of education in Ontario through the provincial budget. We know it has gone from its once high of slightly over 60% to somewhere in the 40% level. We would recommend that every attempt be made to resist any reduction in that level of transfer payment.

The grant transfer system, as you well know, was designed to equalize the taxation effort and support equality of education across this province. We believe the reduction from the 60% to the 40% is having its impact on the ability of some areas to provide equality of educational opportunity. A further reduction in the level of transfer grants would exacerbate that problem.

We do see a possibility of saving in the integration of social services. At the present time, three ministries seem to have some overlap. A clearer definition of the role of schools and the relationship of the school to the delivery of social services, we believe, would result in greater efficiency. One has to ask the question, should educational dollars be spent to deal with needs that could properly be addressed through either the social system or the health system? The federation is prepared to work with government to see that saving realized in this area.

We are of the opinion that uniform criteria for the provision of transportation and the co-ordination of transportation among coterminous school boards has the potential for substantial saving. We also believe that uniform and improved accounting practices would permit useful comparisons and facilitate informed decision-making both at the school board and at the provincial levels. OTF is prepared to support and to participate in initiatives designed to ensure that the best use is made of available resources.

Major building systems in this province are reaching the end of their life expectancy and we know renewal and replacement is a major demand. New student places are required in areas of the province that are expanding. We are of the opinion that the extreme budget crisis is temporary and we believe that savings could be achieved on a short-term basis by delaying some of the provisions for capital expansion.

Schools are recognized as the cornerstone of democracy and we believe they are critical to the development and maintenance of a strong, vibrant economy. It is particularly important in difficult economic times that the commitment of the government to a strong, healthy system of public education not waver. OTF would urge you to protect the next generation and its education in your budgetary deliberations.

You will find when the five affiliates present that there may very well be some points of disagreement, for each of us as an affiliate has a unique perspective on education in this province. I am going to ask each of the five affiliate presidents, or the four who are here, to make their presentations to you in turn. If their comments raise specific questions, when you question our group, I would ask that you direct that question to the president whose brief raised that point. I think you will get a more specific answer than you would coming through me. In my role as OTF president, I am looking at things as an overview.

With your consent, I would now ask the president of the Ontario Secondary School Teachers' Federation, Ms Barkley, to make her presentation.


Ms Barkley: I thank the committee for listening to our presentation. As I take you through the brief, I would like you to understand that we are just going to highlight various parts of it we think will be of interest to you.

We have the executive summary on page 1, one of the things our Premier has said is, "Our most important resource is human capital," the human beings. One of the ways we develop that human capital, of course, is through the educational system. We have seen that development in Germany and Japan, where they put a high price on and input into education, and we recognize how competitive they are. We also recognize in places like Mexico, where that does not occur, they are not globally competitive. We would like to stress that particular point.

We would say that in 1991 the Ontario budget was very helpful to the educational system. It permitted very modest mill rate increases in most instances. I would indicate to you that we took the brief we presented to you across the country, to BC, to Saskatchewan, to the territories and Nova Scotia, and they too found that particular brief and the approach of the Ontario government to education to be a very helpful one to them. It certainly motivated them.

Within the context of Ontario, you know there was a tax revolt coalition, which all of us here dealt with as best we could, and you see some of the kinds of material we utilized. I think those that supported quality education made a big impact in that particular election. For example, my facts that morning were that there were 11 tax revolters who ran and 11 who were defeated. But we do know that particular coalition is not going to go away just because the election is over, so we -- I think it is we in this room who support quality education -- have to be ever vigilant and have to make very sure that the people of Ontario understand that it is an investment for the whole of Ontario and for its economic future to look carefully at the kinds of funds we maintain within the educational system.

I would say too that, though we recognize the economic crisis, we also know that it will be over in time and that in the process we cannot let the whole system, nor our buildings, for example, our capital funding, deteriorate. So we still support, if at all possible, the same level of public funding for capital expenditures, $300 million, as last year. If we wait and do not do it, by three or four years from now, the expenditure will be excessive.

I ask you to look at the graph on page 3. Sometimes we think the public is not in support of school expenditure, but if you take a look at this Ontario Institute for Studies in Education poll, you can see how people looked at support for increased school expenditure. It still stays quite strong, in my opinion.

What we have now, though, are some boards that are panicking, and they are cutting what they call non-mandatory staff. For example, in Oxford -- it is ironic -- in order to get anti-recessionary funds from the government to create jobs, they fired about 14 people, who were speech pathologists and psychologists for hard-to-handle behavioural students. They created a real problem in an area where the hospital could not serve these children, and of course what that is going to mean is that these people will become dropouts and will cost us and society more in the end. We have to watch the whole area of education that in these times we are careful how we deal with cuts in education itself.

As with you, as with all the affiliates, we have always been in favour of some form of tax reform, be it in the property tax, certainly in the taxes corporations pay, etc, but now dealing with education, if you take a look at the graph on page 4, "Government Grants as a % of School Board Expenditures", our share is at 41%. It is too low. There is widespread support for property tax reform to shift more of the burden to a more progressive base, but at this point in time the provincial share is too low. You will see what I mean as we proceed through this.

On page 5 -- and this is something we have said on three different occasions in this forum -- there is a question of high wage or low wage society, Mexico or Japan and Germany. We believe that if we go the high wage route, that is, pursuing the education of our youth and our adult population, we will be competitive. If we go the low wage route, as they have done in Mexico, we could well end up with a society like theirs and massive unemployment, and also a really discontented population.

The federal government seems to be seeking competitiveness through a low wage, low social expenditure strategy. We support the Ontario government's direction outlined below. As you said in your last budget, "Ontario cannot afford the rigidity induced by policies which focus on cutting wages and eroding public sector contributions to productivity." The alternative approach is for government to play a role as a facilitator of structural change to promote the development of high value added, high wage jobs through strategic partnership. We still support that strongly.


The Ontario elementary and secondary schools want to make education a lifelong learning. I will show you this. I know you cannot all see it, but this was at the beginning of a school year in Metro Toronto alone. There were 380,000 adults in Metro who went into our school system. In my home of North York, for example, there were 100,000 adults in night school, Saturday school and summer school, compared to 58,000 adolescents, showing you the massive need for that kind of lifelong continuum. We are very much in support of that particular need, as I know the Ontario government has indicated it is.

Going a little further, and I think this is something you may not really be aware of, at the bottom of page 6 we are talking about fiscal effort, as defined by Statistics Canada, as a percentage of per capita personal income that goes to fund local elementary and secondary schools. One of the facts that is going surprise you is that we were 9th out of 10 -- not last -- on per capita personal expenditure vis-à-vis income. We are now last, 10th out of 10 in Canada. Take a look at the graphs on page 7. Provincial expenditures on education have declined. Again, any way you want to look at it, we have become last, and this is not good.

On page 8 we are comparing all the educational systems around us: Quebec, New York, Pennsylvania, Minnesota. Again, the only ones below us there, I believe, are Ohio and Manitoba. We are competing with all these other systems and their end product, and we are not doing well. We have to take a look very carefully at that and the effect on our labour force and our ability to compete. Again on page 9 we emphasize that particular point.

We bring in these graphs because it is the only way to really illustrate the problem we have. They come from Statistics Canada. On page 11, though it is a little muddy there, is where we got the statistics from, for those of you who want to study and peruse this particular thing.

Going on to page 12, what we have here is an indication, right through to page 14, of the study that was done in Princeton which indicated that the more money spent on education, the better the lifelong earnings were of the people who were served, and of course that was reflected in taxes into the economy. That is for your perusal.

At the bottom of page 14 you can see the transfer payments, which you know only too well, and the disastrous effects of those cuts. One of the things we are a little dismayed at is that neither the particular government nor the opposition parties in Ontario make enough propaganda about how the lack of transfer payments affects Ontario and the country.

On page 15 we have statistics on corporate and personal income tax. In 1950, corporate income tax was 49.7% down to 7.4% in 1991; personal income tax was 11.7% in 1950 up to 37.1% in 1991. I do not have to say more. You can see that shift very well, and we know the NDP, through the Fair Tax Commission, is looking at the changes that have to come within the whole taxation structure, but we do not think we can wait that long, for example, for the corporations to begin to pay their fair share. No matter what kind of hits you get from big business -- they will hit you no matter what you do -- you still have to do the right thing and the corporations have to pay their fair share. They have in other provinces. They have in many of the states, and contrary to the threats they give, I think it is essential that we start to force them to do that.

I proceed about other things we think in education are terribly important. I stress the question of sharing, and there should be sharing. OSSTF supports sharing, for example, in busing. There is no question it is highly expensive. The Auditor General told us that, and he is right. We should take a very careful look at that with input from the affiliates of how it can be done, but it should be done. We should look at things like sharing for technological studies, equally expensive, or special education services or in administration in the business area, co-operation in purchasing and warehousing and maintenance. All of these things we should look at for sharing. There is immense duplication and immense expenditure there, and that is the kind of expenditure where real savings can occur, so we ask you to look at that.

In the transition years, we cannot at this point in time afford the whole of restructuring. Of course there has to be reform, but take a really good look at destreaming, where it has been implemented: Rosedale Heights, for example. It is immensely expensive. Just ask somebody what the cost is of this whole restructuring process. I suggest, in this crisis, that you slow it down a little bit and see what ones are really necessary, because we are getting ourselves into difficulty.

As I have been told by all quarters my time is up, I would just ask, if at all possible, that the recommendations in some form be read into the record. I thank you.

Mr Poste: Is it your wish, Chair, to question the presenters after the brief, or do you wish to hear from all of us first?

The Chair: We prefer to hear from all of you and the rest of the period will be reserved for questions.


Mr Poste: I now call on Susan Owens to present the brief on behalf of the Federation of Women Teachers' Associations of Ontario.

Ms Owens: I would like to introduce my colleagues from FWTAO who are here with me because I have brought them along to answer all the tough questions that are going to happen shortly: Margaret Dempsey, who is first vice-president of FWTAO, and Marilyn Roycroft, who is the executive assistant responsible for communications and political action.

We are here today on behalf of the 40,000 women who teach in our public elementary schools. As we have for the last number of years, we want to speak not just about adequate funding for the education of young children, but about some wider social issues as well. We also want to acknowledge at the start that we, along with my colleagues who spoke before me and along with most of the people in this province, recognize the serious problems in our economy and we know how difficult it is at this time for a government even to maintain the funding for existing programs.

But we want to emphasize that the responsibility facing any government, regardless of the economic times we are in, is to set priorities for spending. There may be fewer dollars than anticipated, but where they go should reflect both the principles and the ideals of the government. So what we are going to deal with today is our view of what the government's priorities should be, given the limited funds that are available.

I would like to focus on three key issues. First, the financing of education: For more than two decades our organization, FWTAO, has submitted briefs and made presentations on the subject of education finance. We believe major changes in education funding in the middle of the review process would be a very grave mistake. Adequacy and equity are guiding principles in education finance. We also believe it would be very helpful if all the review processes that are in place right now were able to determine the true cost of educating an elementary student.

Second key issue: We are very pleased with the growing public awareness of the importance of the early years in a child's education. The ministry's initiative to reduce class sizes in grades 1 and 2 is a recognition of this importance. We believe, however, we need smaller class sizes in all grades. We now know without question that what happens to children in the early years largely determines whether they will be successful in school and actually remain there. In fact, research has shown that money spent on early education is money saved from future remedial and social programs. With regret, I must speak in opposition to the Provincial Auditor's report that says there is no correlation between class size and effective outcomes for children in the future. Elementary teachers want to do the best they can for their students, but they must have the class size, the preparation time, the adequate support personnel and the proper facilities to do the job.


Third key issue: The measure of a civilized society is how well it protects the most vulnerable, and we believe that we must make poor children one of our priorities and one of your priorities. We presented a brief called Poor Children in Ontario Schools to this committee in January 1990 and also in January 1991. It was a clear call to action.

The recently published report of the Child Poverty Action Group supports our call to action. It documents the appalling numbers and the fate of one child in six who happens to be poor right now in Ontario. I quote from that: "To be born poor is to face a greater likelihood of ill health in infancy, in childhood and throughout your adult life. To be born poor is to face a lesser likelihood that you will finish high school, and lesser still that you will attend university.... To be born poor is simply unfair to kids."

In the past two years, in my capacity as vice-president of FWTAO prior to being president, I have had the opportunity to visit over 60 school boards in Ontario. I can corroborate the fact that our teachers see the face of poverty in the faces of their students every single morning -- hunger, abuse, neglect, drugs and violence.

We have suggested both short-term and long-term solutions that should be priorities for this government, and I would just like to point these out. There are four:

1. Provincial funding should be available for school meal programs and nutrition counselling. It is our belief, however, that those programs should not be solely government-funded. The communities must be involved. They must make the decisions about what programs would be appropriate for them. But we believe we have to make it happen, and that is where provincial funding comes into play.

2. A provincial push for a substantial increase in low-cost and non-profit housing.

3. Provincial funding for health care professions to be in schools.

4. Provincial recognition that child poverty is part of the feminization of poverty. Government action on accessible, affordable child care, fully enforced pay equity, mandatory affirmative action and better training opportunities for women.

We commend the government for taking action where parents default on support payments. That one change, we believe, will have a dramatic and positive effect on many of our children's living standards in our schools.

The recommendations of the Social Assistance Review Committee's 1988 report were insightful and far-reaching. We continue to believe that people should be helped to move from dependence to self-reliance and we urge the government not to waver from its commitment to job creation, increased minimum wage and income supplementation for the poor.

Finally, we want to stress the importance of co-ordination and integration of the health and social services presently available to poor children, families, communities and schools. In our Response to the Formative Years Consultation Papers in February 1991, we said we needed five things:

1. Community-based programs to involve and educate parents and teachers about drugs and child abuse.

2. The co-ordination of and an increase in special services.

3. The integration of child care.

4. Co-operation among all of the education groups in terms of resources and expertise.

5. Co-ordination and sharing of recreational facilities.

In summary, we argue that during review processes of educational finance and funding, adequate funding levels must be maintained. We urge you to give priority to the needs of poor children, women and poor families. We believe very strongly that when the poverty cycle is broken, every single one of us gains.

We hope you will recognize that a typical home may have any of several social problems, and a child who comes to school hungry or hurting or frightened will never be able to learn.

Our members are part of their communities and they are seeing and they are also feeling personally the effects of this recession. We believe co-ordination of services may be a better use of current resources. Our chair was actively involved in the Children First document. We totally support the concepts that are put forth in that report.

We believe the co-ordination of services has the potential to help all children in need to develop socially, emotionally and also educationally, and all at the same time. These are the priorities of our federation. We hope you share them and that they will be reflected in your recommendations. I thank you for having the opportunity to present today.


Mr Poste: Our next presenter is Michael Coté, president of the Ontario English Catholic Teachers' Association.

Mr Coté: The Ontario English Catholic Teachers' Association is pleased to appear before the committee to present some of our views on the 1992 provincial budget. Just a few months ago we appeared before the committee to provide a reaction to the 1991 budget. In our concluding comments, we recommended that "the wellbeing of the citizens of this province remain the number one priority of Ontario legislators."

We wish to reinforce this statement and to indicate that our priority must be our people, well nourished in mind, body and spirit. In order to achieve this goal of a well-educated, healthy citizenry, we must continue to adequately fund our social institutions. On the issue of adequate funding for public and separate elementary and secondary schools, we make the following observations.

1. The majority, over 95%, of school boards in this province spend beyond the grant ceilings established by government. The ceilings must be raised in order to provide more equitable access to education dollars.

2. Downloading of education costs from the province to local school boards must be reversed. This is a regressive form of taxation and does not place the burden of education costs fairly on those who have the ability to pay.

3. The Ministry of Education is currently undertaking a massive review of the educational system. Many of the proposed initiatives have significant financial costs. We cannot create new and additional educational reforms while at the same time flat-lining or seriously limiting major transfer payments.

4. Capital financing of facilities deserves a closer look. A recent survey of our organization indicates that approximately 20% of students in the elementary and secondary schools are housed in portables. Copies of our September Agenda newsletter and the Reporter magazine that we send to every one of our teachers give the details about this serious lack of facilities, and they have been distributed to the committee members. I hope they will have a chance to read them later on and see the seriousness of this problem of 100,000 of our students housed in temporary facilities.

OECTA recognizes that the current recession has had a major impact on the Ontario budget. Yet we believe we must continue, as the government did in the 1991 budget, to invest in our future, in the education, health and social programs of our people. As I said, we were here just a few months ago praising this government for the action it took, and I hope you will stay the course. Now is not the time to do an about-turn and go 180 degrees in the opposite direction.

We are not as pessimistic as some and know that our investment will pay great dividends. In a recent Conference Board of Canada survey of forecasters, the average economic growth predicted for 1992 was almost 3%. Economic research reports from the Toronto-Dominion Bank and the Bank of Montreal indicate similar growth rates in the 3% to 3.5% range. We have some charts at the end of our brief to support that.

Just by way of an aside, I found it very interesting in the Toronto Star's business section yesterday to read that the Bank of Montreal showed record profits again in 1991. The bank's profits went up by 14% -- $73 million -- for a total profit of $595 million. That 14% profit was based on 1990, when they had record profits. It makes it a little difficult when you read figures like that to think that everyone is suffering equally in this recession.


In order to balance fiscal responsibility of the province with the reality of education costs, and following a move to increase the grant ceilings to a more realistic level and to stem the flow of downloading educational costs, OECTA recommends to the committee that increases in the 1992 legislative grants to school boards be cost of living plus 2%. While this may not address all the immediate educational needs across the province, it will at least maintain a quality of program of which we can be proud.

The Ontario English Catholic Teachers' Association commends the government for its initiatives this past year and supports any recommendation of this committee which will maintain and enhance our vital social institutions.

Just to take you quickly through our charts that are appended to this brief, the first one, on gross domestic product from Statistics Canada, shows that the forecast for 1992 is growth in the range of 3.5% and, for 1993, 4%.

The second chart lists several Canadian economic indicators. The source again is Statistics Canada. In the quarterly indicator down near the bottom, the gross domestic product annualized percentage increase, first quarter of this year to first quarter of last year, there is a 4.9% increase.

The third chart is headed "Ontario Leads Provincial Growth Forecasts." The real gross domestic product annual percentage change shown there, again from the Conference Board of Canada, illustrates that Ontario is projected to have a 4.5% higher increase than any other province.

The fourth and last chart, one of the leading indicators, "Housing," from Statistics Canada and Canada Mortgage and Housing Corp, shows that real housing expenditures in Canada will grow by almost 6% in 1992.


Mr Poste: Our next presenter is Gene Lewis, president of the Ontario Public School Teachers' Federation.

Mr Lewis: Ladies and gentlemen, I will be referring to the green document. As Ron said, I am Gene Lewis, president of the Ontario Public School Teachers' Federation. I am joined here today by David Lennox, our secretary, and Vivian McCaffrey, our legislative observer.

While many recommendations are presented in the report, I think the key for all of us to recognize is that Ontario's greatest resource is its children. The document is intended to urge and encourage those who set the provincial budget to continue to support our education system in a manner that will allow the children of Ontario to learn in safe and secure surroundings and allow them to maintain their health and their dignity in times when many of the families are facing challenges, as we well know. I would like to say that we appreciate the timing of the consultation this year. While we have made many presentations in the past, we think the timing is more likely to facilitate impact on the budget processes.

During those many presentations in the past we have often focused on the structure of education finance in the province and the most obvious need for change. This year's brief, however, does not focus on those structural problems in the financing of elementary and secondary education because of the work of the Fair Tax Commission. We want that commission to have every opportunity to bring a new structure to education finance in Ontario.

I suppose our major concern could be directed to the minister's comments that were reported in the Globe and Mail on November 19 about a possible 3% or less increase in transfer payments to school boards. This brief focuses on what the potential effects of limited transfer payments and minimal increases could have on education.

On various pages in the brief, we comment on some of the cutbacks. Last June in a presentation to this committee, the Treasurer commented that simply flat-lining the transfer payments would result in one of two options: a 4.2% increase in local property taxes or the closing of 6,000 classrooms in the province. Both alternatives of course are quite unsatisfactory.

Another impact of inadequate transfer payments would be larger class sizes at a time when our curriculum and the services we provide to children require that class sizes continue to be at an acceptable level. We appreciate the initiatives of the previous government in that direction at the grade 1 and 2 level and the support of this government in maintaining those class sizes.

If school boards are forced to cut services because of inadequate transfers, the likelihood is that non-teaching personnel may be affected, the psychologists, the psychometrists and the social workers who provide the services to the children who in today's economy are most likely to be found wanting and in need.

Additionally, the government made some movement last year to address the gap in funding between elementary and secondary education. That was appreciated. Inadequate transfers would not allow that to continue.

I think realistically we have to look at the impact on school boards. For the most part in this province, school boards have made a commitment to maintain quality services to children. If the funding does not flow from the provincial body, then school boards are going to be forced into cutbacks of programs, which they do not want to do. We will see increasing pressure for fund-raising at the school level, which provides many inequities based on communities. The pressure on school boards to force child care centres out of the schools as enrolment increases would be another area where we would have significant concerns. I think all these examples would affect the children and the families who are most severely hit by the current recession and, as such, are untenable.

We point out in the brief some potential areas of cost saving. We are not quite as optimistic as Douglas Archer; we do not see tens of millions of dollars in saving. We do see there is potential for some saving by the sharing of transportation services, administration and purchasing among coterminous school boards. We are concerned about some of the recommendations, however, because their focus is purely fiscal and does not focus on the needs of children. While shared busing may generate financial savings, it could also create difficulties for kids and their families. We cannot have as our focus purely the saving of cash.

As suggested in the document, sharing should be voluntary and should respect the constitutional rights of the Roman Catholic community and the minority-language educators. We suggest that pilot projects and studies in this area would be worthwhile endeavours.

Another area where we are looking at the possibility of cost saving, as was mentioned earlier today, is the integration of children's services. We suspect the government will want to study the possibilities there, because we believe there is an opportunity to provide better services to our children and to save on administration costs.


On page 11 of the document, one of the areas we focus on is support for the request made by the Ontario Coalition for Better Child Care for $45 million to pay for 5,500 additional subsidized spaces and to maintain the 1990 level of program funding for child care in the province. We point out the fact that there really is not an adequate system of child care in this province. There is not a system that provides adequate accessibility to the children of working families, and action needs to be taken in that area.

Finally, while the recommendations are before you, OPSTF does not support cutting expenditures in social services. At a time when many of the families in our province are suffering, we cannot take the social support systems away from those people. We suggest it would be better, in the alternative, to introduce modest tax increases if necessary and to allow the deficit to rise a bit more, because we also share OECTA's optimism that while we are upon hard times right now, we see some brightness in the future.

We appreciate the opportunity to speak with you this morning.

The Chair: Thank you very much. You have all presented and I am sure there are questions. I repeat once again that if you wish to refer some to the staff you have with you, please feel free to do so.

Mr Wiseman: I would like to thank you for your presentation. Just to give you a little background on where I am coming from with my questions, I spent 15 years in the classroom in a secondary school and I have currently two children in an elementary school, one of them in a portable and one probably soon to be in a portable, in a board that has 489 portables in the public school sector and an equal number in the separate school sector.

It is a board that seems to be wealthy enough that it is currently thinking about debenturing and planning to debenture a new office administration building to the tune of $26.2 million. Just to give you some idea of the importance of that $26.2 million, when the Durham Board of Education brought forward its list of priority spending, in the first four the total was $8.7 million. But that board refuses to spend any money other than money from the province to build capital structures.

My priority in terms of education is, what does it have to do with the student right in the classroom and what is the effect? If you are going to spend money on administration someplace, how is that going to affect me as a classroom teacher -- when I was a classroom teacher -- and how is it going to improve the education of the students? I would like some comments from you on the idea of debenturing schools.

Ms Barkley: I have heard about the situation in the Durham board, of course. If I taught in the Durham board, I certainly would do two or three things. I would make a presentation of a parental group to the board of education, being shocked and appalled and deploring, because you should be. Certainly a petition should be signed in the community. With the educational dollar and all other dollars, each one we count being important at this point in time, with no excesses, I think that kind of expenditure should be exposed and opposed.

I would get some friendly trustees -- there are one or two I know of -- to try to head that up and organize within the community, because that kind of expenditure in this kind of climate is absolutely unacceptable. That should be made abundantly clear. That is not where we would put the educational dollar or where any of us would say the educational dollar should go. So I would start to organize within the community itself. Probably in many cases they are not aware.

Mr Wiseman: I was on the stage on Wednesday night in a school that has overcrowding. The unfortunate consequence of their school building washroom space for 1,200 students was that they got all the portables and the other ones that were being built did not.

My other question is on the busing and combining some of the costs. My community has a rural component. A separate school bus comes along and picks up some children and drives along half full to the school, and then the public school bus comes along and picks up the neighbour's children and drives down to the school that is right across the road. Yet what we are hearing is that the administration of the separate school board will not contemplate combining busing. How much time do I have left?

Mr B. Ward: Before you answer --

The Chair: Excuse me, Mr Wiseman, may I interject just for a moment? First of all, I would recommend that your questions deal with the global in the group. We are dealing with pre-budget hearings.

Mr Wiseman: They did mention combined busing in their briefs, so I just wanted their comment about how we could achieve that in boards that are reluctant, that are just going to say no.

The Chair: You are going to generalize the question.

Mr B. Ward: A point, Madam Chair: How much time does each party have? I recognize there is nobody here from the third party.

The Chair: I had hoped, seeing I saw no early response, that we would be able to just forward the questions, especially since Mr Sterling has had to leave, but if in fact we are going to have to divide the time up according to parties, it is going to be a little overweighted.

Mr Wiseman: We have got lots of time left.

The Chair: If I see there is a problem, then I will certainly move from them and on to you.

Mrs Sullivan: I have lots of questions.

The Chair: All right. Mr Wiseman and others, please make your questions concise and direct. I understand you have an answer, Mr Lewis.

Mr Lewis: Having come from a rural background myself, I understand that is the situation. We recognize there are cost savings that can be effected, but I think the question is more properly redirected to the government, to provide some leadership and some assistance and some encouragement to allow school boards to co-operate effectively.

The Chair: Is there anyone else who would like to respond to the busing? Mr Coté?

Mr Coté: What we would suggest as an idea to be explored -- we think it has some potential for cost savings here -- would be that there be a commission in each municipality that would deal with the busing for both school boards or all school boards -- if you have a French school board, there could be three coterminous boards -- and that this commission, I will call it, would organize the busing for all the students. There would be one organizing entity for the municipality and the busing would be provided appropriately and equitably for all the students and the boards would pay according to the number of students they transport.

Mr Wiseman: My last question is a quick one.

The Chair: I think there are two other comments on this.

Ms Barkley: I think this busing thing points out something we indicated in our brief. One of those things was, if you take the Ottawa area, we have five boards of education in Ottawa with 88 trustees. The duplication there is massive. I would suggest to you, whether a board likes it or does not like it, when there is duplication which is a waste -- and your example was a good one -- I do not think it is the board's choice. I really do not. I think we have really massive duplication which is a waste -- I say Ottawa, my own group included -- and it should be looked at and should not be allowed. Certainly if it could be done sensitively, as Mike points out, all the better, but if it cannot, it should be done in any case.

Ms Owens: Just one final comment about the busing issue. I see it as a very similar issue to the whole integration of children's services, that we have to look at ways we can be more effective in how we use the money. But if I can reflect on one of the comments that was again made in the paper about a procedure for cutting down on busing costs, we would have to look at what we talked about in our brief, the principles and the ideals. For us the focus is children. We have to make sure that whatever we do, it is for the betterment of the young people and not just for cost-cutting measures.

The Chair: We are going to move on to Mr Jamison. If there is time we will come back to you, Mr Wiseman.

Mr Jamison: I would like to thank you for taking the time and making the effort to put these presentations forward. I think it is very important that you be here today to be heard, and I do agree it is timely that you be here.

I have heard from a number of the presentations today that there is a realization that our economy may have bottomed out and, to use the Treasurer's expression, is bumping along the bottom at this point, hopefully finding the step to get things under way again.


The revenues of the province are down. Revenues were forecast to decline by 1% this year over projections. At the same time the province had to cope with the federal government deficit and its policy of offloading on the provinces in the form of lower transfer payments. Just for an example, federal measures taken in the 1990-91 budget alone are estimated to have cost Ontario $1.6 billion in the form of reduced Canada assistance plan and established programs financing transfers that normally take place.

I understand that the problem with downloading is one that is there and I understand that what you are saying is to maintain adequate funding through this period of time. Certainly our intentions are to stay at the deficit levels we forecast. I have two questions. This is the first: Where would you see the money coming from in trying to stick to the projected level of deficit that we feel it is important to try to stay at?

Ms Owens: I would like to respond in three ways. First of all, I believe that it is not our responsibility to tell the government how to develop the plan but to say that we have a philosophy that guides what issues are important. That is number one. I think there are some creative solutions, and I go back to the integration of children's services. There are ways that we could probably use the same amount of money but more effectively and more efficiently. I think that is very important.

The third thing I would like to highlight that we talked about in our brief is that we do not want to make short-term cuts that are going to have profound long-term effects. I go back to our comment about the fact that money spent on early education is money saved in future remedial and social programs. We know what has happened in the United States when funding has been cut in education. It has had drastic negative effects on the future of the children.

Ms Barkley: This deals with your question and it deals with the question put by Mr Wiseman as well. Traditionally school boards have debentured to build schools. They have often done that. Now is a good time, as construction costs are low and interest rates, as you well know, are going down, for Durham to look, for example, as others should, at debenturing. It should be a suggestion this government makes when there are capital needs. That would be one thing.

I will go back again. There are two solutions. Susan has certainly mentioned a few that we would support as well. But you do have to look -- and I know the NDP is reluctant to look at it -- at the corporations that are basically tax-free in Ontario. If you look at Maude Barlow's whole list of corporations, 60,000 or so, etc -- I think you have to take a look at that. Whatever the public heat is, it is a real factor. We can compare ourselves with other jurisdictions and that is not there. They are not good corporate citizens. That is another one.

Again, I know I may not be too popular when I say this, but the duplication of services has to be looked at without any incursion on the Catholicity of the other system or the Frenchness of the other system. There are a whole lot of things that we can do that can save literally millions and millions of dollars, and it is not just on busing.

I give you those three suggestions as ones that at least should be looked at. Again, if we can hurry up the work of the Fair Tax Commission, that would be helpful as well.

Mr Jamison: One part of your report is very concerning to me and I am sure to many of us. That certainly reflects part of the answer that was given. That is the need for proper housing, the need to address poverty and the needs in the area of child care and how that can affect the education system. I understand from information I have received that the very early child education years are found to be more and more important as to their effect on the early development of a child's education and are paramount to their prospects for success in life. I wonder if you would like to make a comment on that.

Mr Lewis: One of the positions this federation has held for a number of years is the inadequacy of elementary funding in the province and recognizing, as you say, that the maximum benefit from tax dollars is achieved through early education. The other issue I think we have to recognize is child care. The whole lack of a system of child care needs to be addressed seriously by this government, and the fact that only 20% of the children whose parents work in Ontario are in licensed facilities. There are 5,500 vacant spots and 12,000 eligible children for subsidy on waiting lists. It does not jibe. Those issues have to be addressed. I think there is a growing recognition among all communities that it is essential to put the resources at the early levels.

Ms Owens: Just to acknowledge what you are saying -- and obviously it has been a key point of ours for years of presentations -- I draw your attention to the sources we have put in the brief. I think each one will document clearly the importance of the early years and how critical they are to children's future successes. I also draw your attention to people like David Weikart, who have done studies about the importance of the early years and the long-term effect. A book I am working my way through is called When the Bough Breaks. It has a focus on the American system, but clearly states that if you do not have those support systems in place for children, we are all going to pay in the later years.

Mr Poste: I would like to take a slightly different approach to it. You hear us regularly speaking on behalf of children and in our opinion these members of our society are in a position where they really are totally dependent on adults and not in a position to help themselves. In our brief we indicated there is a fair bit of overlap in various ministries. When we look at lack of action, or trying to promote action, quite often our suspicions are that there is a lot of goal-tending going on in the provision of services in the field. The government may very well want to consider whether it wants to take a hard line and put the people who are in a position to have a greater control over what is happening to them -- and I am talking now about the adults of our society -- into a position where the children are going to start to get a priority because they do not have the opportunity to control their destiny in the same way.

Mr Coté: I fully agree with the comments made by my peers here about the value and the economy in the system and so on. Everybody wants to see good value for their dollar and we want to run the system in the most efficient way possible, but something that has not been said clearly enough is that we do not have enough money in this system right now. It is clearly underfunded. At the risk of being as popular as a skunk at a garden party, we have to raise taxes. We need more money.

The statistics OSSTF had show you that on the basis of comparing average incomes to the percentage that goes into education, we are the lowest in Canada. Coupled with taking every step to have the most efficient economical system, the best value for our dollar, we need more dollars. It is going to mean a higher provincial income tax.

Ms Barkley: I support my colleagues when they say there are a great deal of resources we could and should put in to the young child. There is no question about that. As you examine that, just remember that if you take a look at the boards that were forced to spend over the grant ceilings, the amount they had to spend over the grant ceilings on secondaries far outweighed that in elementaries because of the real, pragmatic cost of the education of a secondary school student. While supporting the stress on the young child, do not forget the other part of the equation as well. Therefore, I support what Michael says. The problem is, we do not want to get into a situation where it is one or the other. That, of course, we want to avoid. Both needs are there.


Mrs Sullivan: Some of you may not know that Liz Barkley and I were in university together and she is just as feisty now as she was then.

I was very interested in reviewing the recommendations with respect to the upcoming budget from each of your reports. Some of you were quite specific in making recommendations about transfers and drew some conclusions from those recommendations. The 60% funding level rode through each of your presentations. I think it was mentioned in virtually each one of them.

I recall sitting in stunned disbelief about this time last year when Marion Boyd, then Minister of Education, appeared before this committee and told us for the first time that the New Democratic Party commitment to 60% funding of education included teachers' pensions, capital and a cap on the approved spending and not the actual spending. She indicated that is what she campaigned on and she thought everybody understood that. I think we were all quite taken aback. People from the teachers' federations were certainly taken aback at that statement.

I am interested, however, that until there is a new recommendation, the 60% is still a matter of priority for each of the federations and would appreciate some comment on the 60%. I am also interested in the recommendations relating to allocations for this year. I notice that the public school teachers' federation is specifically requesting rate of inflation, about 3.3%, plus 1% to 2% for growth. OSSTF is indicating inflation. The English Catholic teachers' association is indicating inflation, 3.3%, plus 2%. I do not think there was a specific recommendation from the women teachers' associations.

The underlying assumption of 3.3% inflation, plus 1% to 2% -- I think one of the organizations represented the additional as necessary for growth -- was that amount of transfer would keep the system at its current level. I believe that is included in at least one of the briefs. In my view, and I believe in the view of people looking at education financing, inflation plus 1% or 2% indeed will not keep education at the current level of service in the system. I would like comments on the 60% as the actual request you are bringing forward to the Treasurer, because that will underlie some of the recommendations we make.

The other thing, as we look at the transfers themselves, the MUSH sector, the universities, schools and hospitals, which is very apparent is that in every one of the universities schools and hospitals sectors, the service sectors dealing with people, a very high component, usually over 75%, of the expenditures in those areas relate to salaries and benefits for people who work in the system. The Treasurer has indicated to the Ontario Hospital Association that he has spoken directly with the unions which represent hospital workers, the Canadian Union of Public Employees, the Ontario Public Service Employees Union and the Service Employees' International Union, and asked them to hold the line on their wage requests. I wonder if the same request has been made of teachers and other people who work in the school systems and what your response has been.

Mr Christopherson: Yes or no.

Ms Barkley: Exactly. I would like to go back to what I think is the most important point here. I would agree with your assessment. When we say 3% inflation I think it is an incorrect way of approaching it, because that 3% does not have the GST included and now it is going to be taken out of inflation, but it is still there. It is a cost. As well, if you look at the package of goods on which the federal government assesses inflation, it does not include what it did 10 years ago. We have to go back and take a look at what is inflation, or that 3%, because I do not think that is real cost. I tend to agree that it has to be looked at again. There is no question about it, if it is just 3% next year and transferred to the municipalities, there will be massive cuts. You are absolutely correct.

I agree, if it comes, it is not going to be satisfactory to the system. The municipalities will be forced to cut so that should be reassessed, possibly by the government, the opposition parties and ourselves.

There is another problem. We have always had 60%. As we look at the grants and try to assess the real transfer, they do not make sense. We have to have another way of financing education which I think both opposition parties, the government, ourselves and the affiliates are looking at. What is the true cost of education? The grants do not reflect it realistically. We have said 60% because that was at a time when education was adequately financed. As we go through this whole look at tax reform we will come up with another approach to how education should be funded.

We have to be very careful when we say the government said to OPSEU. Yes, the government did say to OPSEU, and you saw what happened at the Ontario Federation of Labour convention. This is not working because you cannot tell one segment of the population you are going to have a wage freeze and not deal with the private sector in any way. I am not calling for wage controls, do not get me wrong, but you cannot have one arm of society paying for the recession. You cannot do that. We have to look at our whole society. One arm is not going to do it. We would not accept that kind of thing at all. We are not here, because we are public sector workers, to pay for the recession.

I will give you one last point. Every time we have a recession the public sector is attacked and they get stripped. It takes us much longer, if ever, to make those strips back than it does the private sector, so we would not readily accept that kind of wage freeze or controls at all.

Mr Coté: I will start with wage controls. I will not belabour it, but just tell you that our affiliate has taken a very clear position in a recent motion by our provincial executive which we have published far and wide to all our members that we will not support any form of wage controls. Second, on our particular affiliate's recommendation of inflation plus 2%, which was found at the bottom of page 3 in our brief, I would point out that it is irrespective of costs attributed to growth and enrolment, so where a particular board may be gaining students, we are proposing a percentage increase to the grant plus 2%. If a board was in a growth situation, that board might see a 7%, 8% or 9% increase because they have an increased number of students.

On the first issue, what does the 60% mean? I think that has probably been adequately answered. I agree with that. We are referring to what was funded at the 60% level in, I believe, 1973 and we certainly do not agree it is pensions or any of those other capital items.

Mr Lewis: Our brief is one of those that recommends inflation plus an additional 1% or 2%, but I think the people in the room have to recognize that recommendation is in response to the current economy in the province. The fact is that a recommendation of that nature is simply to keep the system from collapsing, it is not to provide improvements.

We are of course quite optimistic about the 60% issue and we are sure it is going to happen because all the parties in the room at one time or another have supported it, generally just prior to elections, so we continue to be optimistic.


Ms Owens: I want to corroborate the fact that yes, there are not specific numbers in our brief, but there are three points that clearly state what it is we believe in. They are all to be found on page 2.

1. We believe major changes to education funding in the middle of a review process would be absolutely inappropriate and in fact a grave mistake.

2. We are very pleased to be participating in the Fair Tax Commission and we hope to be involved in the ministry review.

3. We hope these review processes will look at the true cost of educating an elementary student.

I think then we can talk about specifics, and that is why we did not.

Mr Phillips: I have a feeling when the smoke all clears in a couple of years there will not be much mystery. There is property tax, there are provincial revenues and there are total expenses, and you can figure out the percentage. My question is about the Fair Tax Commission. I think we have your recommendations here. The expectation from the teachers' group that is participating on the Fair Tax Commission is that as a result of that -- I am asking the question, but this is my understanding -- there will be some mechanisms whereby the province will find the solution to its funding of the 60%. Is that the going-in expectation of the teacher's federation on the Fair Tax Commission?

Mr Poste: I am responding personally. I think our objective is that the Fair Tax Commission will come up with a process that will generate required funding for the variety of things Ontario is involved in, education being one of them. The 60% figure that keeps coming up goes back to a commitment made by a former Treasurer of the province. At that time there were certain types of expenditures that formed that 60% basket. Our concern is the same game might be going on in Ontario as the feds quite often play with cost of living: When they do not like the items in the basket because they are creating an unacceptable answer, they change the items in the basket.

Certainly the inclusion of capital expenditures and contributions to the teachers' pension plan was not in the initial 60%. Adequate funding is our objective. Right now we use the 60% because it is at least something tangible we can hang a hat on. We would be prepared to look at other alternatives as a part of that whole approach to fair tax in Ontario.

Mr Coté: Our affiliate is not going into the Fair Tax Commission deliberations with any set percentage we are looking at as a magic formula that if reached would solve all the problems. A phrase that has been coined is equity of outcomes. That is what we want to achieve. We want to see some equity in this province.

I find it very unsettling, disturbing and unacceptable that in one place a board spends in the neighbourhood of $6,000 or $7,000 a pupil and another board not more than 100 miles away spends maybe $3,000 or $4,000 a pupil. When there is such disparity I think what we have is a broken system, not a system that can be patched up or repaired with Band-Aid-type strategies. I think we have to dismantle the system and build a new one that will be equitable so that we really do have equity of outcomes for all our children in this province.

Mr Lewis: I do not think we are looking to the Fair Tax Commission to solve all the problems of the funding of education in Ontario. It is my understanding that commission has as its main focus the review of property tax issues. I think we are quite hopeful that the ministry's own internal review of education finance is going to address, first, the true cost of educating a student in this province, and second, coming up with a fairer balance between local and provincial responsibilities. I would say that we do not put all our eggs in the one basket. We see two avenues to address the issue.

Mr Sutherland: I see Liz Barkley has left. The OSSTF brief mentioned Oxford, and I am certainly very interested in that. Some of that board is covered by Mr Jamison in his riding and he is certainly very concerned. I do want to pick up on the comment I believe Mr Poste made in the OTF brief about co-ordination of services, because my office has been active in trying to do some co-ordination around the speech services as a result of some of the cutbacks that came out.

We had a meeting two weeks ago in our office, the second one, and we had all the providers of speech service in the riding there. I was struck by a comment by the director of the hospital who said this was the first time in the 11 years the hospital has been providing speech services for children that all the players had been in the same room. I think there is a great need out there for co-ordination of those types of services.

I want to direct my question on the issue of co-operation. Mr Wiseman asked a question earlier about that and there was a comment made in response that the government should provide some incentives and take a leadership role on that. What more incentive is there a need for, in terms of trustees making those decisions to co-operate on issues such as busing, other than their specific local accountability to the taxpayers who are saying they have a great deal of concern about the amount their property taxes are going up? I would like some comment on that.

Ms Owens: In terms of co-operation, I would like to talk about the integration of children's services and perhaps put it from that point of view. I think the question you are asking is, why would trustees want to get involved in this other than the accountability.

Mr Sutherland: The comment was made that the government needs to provide incentives, and it seems to me like you are saying there should be financial incentives for coterminous boards to co-operate. Is the incentive not there in terms of the accountability to the local taxpayer to begin with?

Ms Owens: I think if we focus on the reason why we are all there, which is for children, and if we are looking at the ways we can benefit children better, then that is for sure the other reason. The fact that you have related a story where the speech therapists in the hospitals had not ever had a chance to talk to the other groups is very key. That is the kind of co-operation and sharing that is bound to have payoffs for all of us while not necessarily demanding increased money or funding.

Mr Poste: I wish to provide a little more information. Liz Barkley had to leave. The OSSTF is sponsoring an adult education conference today and she is addressing the group at noon. But Larry French is prepared to respond on behalf of the OSSTF brief. If it is your wish, he will do that.

The Chair: You could join us at the table.

Mr French: Could I just say a word about the incentive grants? In fact, as Mr Phillips and Mrs Sullivan might remember, for the last three years we have recommended a system of incentive grants to promote the sharing and co-operation and integration of services. Mr Wiseman has mentioned it. There is a resistance for many reasons to the sharing, even in things like buses where it should be easy to imagine you can do this sort of thing without cost in terms of denomination.

We feel if the Treasurer comes up with a system of incentive grants that really makes it worthwhile for a board to share, the costs will drop. We know the cost will drop dramatically on things like busing -- we have seen the auditor's reports and so on -- and the cost will go down. The local taxpayers will pay less, everybody will pay less and even the grant will be returned because the total cost of the operation is lower. We think this is a model that should be considered in many areas and it could be done in a sophisticated way that does not damage anybody's vital interests.

Mr Lewis: Our brief as well recommends the incentives. I think while on a surface level it is fine to say that boards should respond to the needs of the taxpayers, the political reality is somewhat different. I suggest incentives would encourage trustees to make the appropriate kinds of decisions.

Mr Sutherland: It would seem to me, on that comment, that on the surface level it should be, but Mr Poste's comment about goal-tending I think would come back to be somewhat relevant in this case, that it is in everyone's best interest that we stop the goal-tending and fortress-building that has gone on.

I was wondering if each of you would like to comment on the recent municipal elections. In my part of the province I observed the elections, particularly for school board trustees. We heard some comment earlier about that. I did not see a great turnaround in the trustees, even in my riding where cutbacks were made. There was not a great turnover in southern Ontario. There did not appear to be a great turnover in the trustees. Could you comment? What message did the taxpayers send the school boards about education financing in the municipal elections?


Mr Poste: It was the position of the Ontario Teachers' Federation that good quality trustees be encouraged to run, people who would not have vested interests but would be able to take an open view of the system. Our analysis of the results indicates that the taxpayers and the voters of Ontario did take a good look at the level of trustees. Perhaps my affiliate presidents would have different viewpoints.

Mr French: We were involved up to our necks in the trustee elections in many parts of the province. We were worried about the tax revolt. My director in fact went to Los Angeles and did a Proposition 13 study, which we recommend to you folks. We have a video that is very powerful on the effects of Proposition 13, the tax revolt in California. We produced some brochures about electing quality trustees.

We were convinced the tax coalitions were going to be able to elect people, but in all of the areas, including Kent county, Blenheim, the home of the tax revolt, the tax coalition person did not make it. I think we misjudged the innate good sense, you might say -- we were worried about it -- of the Ontario taxpayer which, I support Ron's view, did come through again. Obviously the citizens of Ontario are concerned about taxation but do not want the kind of radical solutions the tax coalitions have proposed. There was only one great breakthrough and that was in Caledon where the tax coalition people swept the decks with the municipal government. All the representatives from Caledon, except for trustees, are tax coalition people. That is the only place in the province.

Mr Coté: In response to that, our affiliate is currently gathering data, so we do not have a definitive answer for you, Mr Sutherland. But moving around the province and being in various meetings and so on with some trustees, it seems like there has been minimal change. There may be pockets here and there, but we have not identified any great changes or any sweep that has occurred.

I would also like, while I have the microphone here, to answer your first question a little bit about co-operation. I am from Sarnia, Lambton county. About 15 years ago in Lambton they set up the Lambton County Centre for Children and Youth. It seemed to me to work very well to bring all the players together to have regular meetings -- and co-operate. I know as a principal in that school system it worked very well in meeting a lot of the needs of our children that, for whatever reason, could not be provided by the school board directly. They put us in the touch with the people who could provide the services. Then there is the Children First document. I think that is the direction we have to go.

I will also point out that in northern Ontario it is quite common for sharing to go on because of the nature of the communities. Being smaller and more rural, it becomes a necessity to share. Maybe in southern Ontario it is not as practical, but in my own personal experience in Lambton it has worked very well.

Mr Lewis: Commenting on the trustee elections particularly, I believe there were far fewer acclamations and an increased number of candidates in most boards across the province, which I see as a positive sign for education: increased interest and involvement. In response to tax revolt candidates who for the most part were spouting irrational half-truths and offering simplistic solutions to complex problems, the teacher federations went out of their way and put extraordinary effort into educating the electorate. I believe we were successful in doing that and the quality candidates were elected.

Ms Owens: I would like to respond as well, after having listened to some of my colleagues, not to that question but to your first one about co-operation. I think we believe incentives are not the only way we can deal with the issue of co-operation, and I would like to corroborate what my colleague from OECTA talked about. There are examples of excellent co-operative models. There is one in northwestern Ontario right now. A board down in the southwest did a study on compensatory education. I do not think we have to start from scratch. There are processes out there. Where the government can be involved is by gathering in the data and perhaps developing some pilots and then working from there.

The Chair: We will move questioning to Mr Phillips.

Mr Phillips: First a comment, then a question. You taught them a lesson that time you went there, Larry. That was a good story of you at the tax revolt.

Mr French: I am never going back.

Mr Phillips: I would concur with Kimble's point. I observed that virtually all the incumbents did get back in, which is an interesting comment.

My question was on your recommendations on the grant numbers collectively, and I gather there is a difference of opinion, but it is basically inflation plus a little bit. Would that be sufficient to handle the contractual obligations of the boards without a shift one way or another between property tax and the provincial income?

Mr Coté: Right now I believe that would be the case. As you are probably aware, there are people who are in various stages of negotiations. We have two-year agreements; we even have some three-year agreements. Some people, for this coming year, are looking at that as the second year of a two-year agreement, so they are already settled and we know what their figure is. Others have settled next year as a one-year agreement and we know what their figures are. In our affiliate we have about 60% of our settlements already in for next year and the rest are negotiating. I do not know what the ones that are still negotiating are going to receive, so I cannot say if inflation plus 1% or 2% would be sufficient. For the ones that have settled, they seem to be in that ballpark, yes, generally, though there are some a little higher.

The Chair: We will move questioning now to Ms Ward. Have you completed your questions?

Mr Phillips: I completed the question. I do not know whether anyone else wanted to comment on that or not.

The Chair: Was there anyone who wished to comment on that question? All right, Ms Ward.

Ms M. Ward: Thank you. My question was for the OSSTF, something Ms Barkley said, and it is recommendation 7 in your brief. I just want some explanation and expansion. I think I sort of know intuitively, but could you tell me why destreaming is expensive?

Mr French: There is a series of pilot projects throughout the province on the restructuring of the transition years, theoretically grades 7 though 9, and there are a lot of resources going into the pilot projects because of the concern of teacher groups like ours and the other federations that this innovation be done properly. A lot of our members are worried that the solution might be worse than the problem, because thanks to the credit system and the triple levels, we were convinced that the dropout rate had been helped and that it had a dramatic improving effect on the dropout rate. We outlined this in this little brochure we gave out during the election campaigns. From a 30% completion rate in 1956 to 75% in 1986 has been a dramatic improvement.

Therefore, these pilot projects are doing it carefully, with a lot of curricular resources, a lot of training and a lot of personnel. Where they are succeeding, these are the conditions under which they are succeeding, and these are the conditions in which we think it should be implemented province-wide if it has a chance of succeeding.

This is enormously expensive, and we are attempting to get a handle on what the expenses would be, but if you extrapolated what Rosedale Heights is doing to make sure it works as a provincial model, over the 150 boards or so of the province I think we would be approaching something in the nature of $100 million. This is not peanuts to make this thing work properly. The previous minister said she would ensure that it works properly, that there will be proper in-service training before restructuring and proper curriculum materials and proper class size before that happens. We think right now it is too expensive an option. I am not sure whether the other federations agree with this or not, but we are certainly convinced of that.


The Chair: Thank you very much. Are there any other questions or comments on that? Mr Coté.

Mr Coté: Our affiliate did come out in favour of destreaming. The only thing I will say in addition to what Larry has already mentioned, though, is that we too said that contingent upon our support was that the three legs of the stool be there for that stool not to fall over. Those were in-service for the teachers, smaller class sizes so that the individual needs of the children can be met and provision for adequate learning materials to teach the children at the various levels in the one heterogeneous mix of the classroom. We support destreaming. We hope it can go ahead. We think there are very interesting things going on in the pilot projects that we will soon be getting final reports on, but the support has to be there to make it work.

Ms M. Ward: Just one quick question which either one of you could answer. It is very expensive right now because the pilot projects will be continuing to be expensive to implement also. There would be some decline, though, in those extra costs once implementation was pretty well under way. Would that be much of a decline, or were you saying that it will be a continually more expensive system than you have now?

Mr Coté: I think once the basic in-service is done with the teachers who are there now, and assuming that the pre-service that will be done in the faculties of education will allow for the methodologies and the strategies teachers will have to become familiar with to implement teaching to a heterogeneous group, that cost will be a short-term cost and then it will all be in place. When it is a brand-new thing and it is being done for a very few, then I suppose providing the learning materials is quite costly. When it is universal, then there will be an economy of scale there. As far as reducing the class sizes is concerned, that is a cost in the year or years in which you move to whatever number is appropriate, and then it is there and the costs would be constant but there would not be an increase that way.

The Chair: Mr Wiseman, I see your hand, but could I ask if it is a pressing need or is it something we can --

Mr Wiseman: It was not until they brought up the subject of destreaming, and then it became pressing. It is a very quick question.

Mr Christopherson: I did not get a chance to ask a question and I have a very short one. I wonder if I can get it in.

The Chair: Oh, certainly. I did not see your name, Mr Christopherson. Mr Wiseman, you have had an opportunity. I will move to Mr Christopherson.

Mr Christopherson: Larry, you mentioned in your comments that Caledon apparently swept aside the incumbents and it was all the tax-coalition group. I assume your association and maybe some of the others will be monitoring the activities there, the decisions they make and the impacts those decisions make on the community and education system, and I was wondering if we might be able to share in some of those analyses. With a tax coalition group which has a majority on council and can implement its agenda, I would be interested to see what kind of impact that has on a local community, positive and negative.

Mr French: I think everybody will be very interested in what develops. We are seeing more and more the need to take a look beyond just the trustees, the boards of education, and see what happens at the municipal level, because there is an overflow. A lot of the pressure on boards was generated by municipal councillors who were very unsympathetic to what the boards were doing, especially in taxation. The two are interrelated and we will be looking at both very closely. We would be glad to share it.

Mr Christopherson: Thank you. I appreciate that.

The Chair: I am going to arbitrarily close off questions here. I know some of you would certainly be receptive to discussing something after the meeting has been adjourned. I want to take the opportunity to thank all of you who have come here this morning and made your presentation. Please convey our appreciation to Ms Barkley, who had to leave. Thank you too to the staff who came in support and those other peers who are also here to support. We really do appreciate it.

Mr Poste: If I just might be permitted one wrapup comment, I would like to emphasize our pleasure at being involved at this early stage in the formulation of the 1992 budget. I hope it was clear from our presentations that we believe a strong public education system is critical to Ontario's future and we hope the report of this committee will protect the education of the next generation of Ontario's residents, who will ultimately be contributing to our economy.

The Chair: Thank you very much. The meeting is adjourned.

The committee recessed at 1156.


The committee resumed at 1540.


The Chair: I am pleased to welcome the Ontario Hospital Association, the Registered Nurses' Association of Ontario and the Ontario Public Health Association to present to the pre-budget consultations this afternoon. Thank you all for being here and welcome.

I will explain to you some of the basics. We hope you will present in about 10 minutes, one following the other, in the order you have selected for yourselves. Then after all your presentations, please join us at this table to respond to the questions the members may ask of you.

The order chosen is that the Ontario Hospital Association will present first, then the Registered Nurses' Association of Ontario and finally the Ontario Public Health Association. May I ask that before you begin your presentation you give us your names.

Mr Timbrell: My name is Dennis Timbrell. I am the president of the Ontario Hospital Association. Joining me in this presentation is Brian MacFarlane, president and CEO of Doctors Hospital in Toronto and chairman-elect of the Ontario Hospital Association.

We welcome this opportunity to participate in the 1992-93 pre-budget consultation process. This marks OHA's third appearance before the committee in this calendar year, which has been one of considerable change and challenge for the health care system, both nationally and provincially.

Several major currents have shaped discussion of health care and hospital services and funding. A new relationship between Ontario's physicians and the government has been established and a new working relationship is being created through the OHA/Ministry of Health joint policy and planning committee, as well as the hospital base program review exercise. We have also seen an enhanced attempt by the government to control drug expenditures and out-of-province health insurance payments. We regard these initiatives as positive steps towards the development of a more rational and planned system of health care delivery. The government's long-awaited consultation paper on long-term care redirection and the minister's clarification of the enhanced role for district health councils are further indications of the government's desire to forge a more co-operative partnership with all the parties involved in health care.

At the same time, this year has been marked by a preoccupation on the part of government officials and health care professionals regarding the rising costs of health care delivery. This comes at a time of rising public expectations and demand for high-quality, efficient health care. It also coincides with a period of rising expectations on the part of hospital and other health care workers for greater monetary recognition of the value of their work. The pressure has been mounting steadily as a result of the current recession. There are close to one million Ontarians on social assistance, and almost 10% of the workforce is unemployed.

On November 19 the Treasurer announced that he had a further $670-million shortfall in provincial revenue to deal with, over and above his deficit budget, this time because tax revenues for 1990 were proving to be even lower than earlier projections.

The federal government has identified transfer payments to provinces as an area where expenditures can be reduced significantly. Through Bill C-69 last year, and this year's Bill C-20, the federal government has taken the first steps down the path that could see the elimination of transfer payments, at least to Ontario, for medicare by 1998. As the federal government reduces its share of health care spending, the greater is the burden on provincial governments to maintain the system and to pass the funding pressure down the line.

The growing problem of hospital deficits simply reflects that in health care, as in other sectors, it is the consumers and workers who ultimately feel the pinch. In this case, federal debt control policies combined with the recession and provincial government budgetary difficulties are resulting in layoffs of hospital personnel, bed closures and service reductions.

It was 30 years ago that Saskatchewan became the first province to introduce universal medicare, a concept which has taken firm root in Canadian society. There is now emerging a chorus of people saying that medicare as we know it is in danger. What is medicare as we know it? A lot of people do not really understand that what we call medicare refers to two pieces of federal legislation. One, in 1958, established hospital insurance and the second, in 1966, established comprehensive insurance for medical services.

Since then a number of additional things have been grafted on to that coverage, to a point where various levels of government have realized that the public expectations cannot be met because they are too expensive. As a society, we cannot afford medicare as we know it. We have to live within our means, and so the unanswered question remains, what sort of medicare are we destined to have?

What we think of as medicare is already a piece of history -- a cherished piece, but none the less part of the past. When it was introduced, medicare was strictly an insurance plan. The government just signed the cheques. Today government is stepping into an entirely different role in its relationship with hospitals and doctors. That role now embraces strong efforts to manage the system through increasing fiscal controls.

There are a number of things challenging medicare. The most immediately pressing is the short-term economic situation that has created the current recession. A major consideration that has been driving discussions of the need to reform health care as we know it is our aging society. People are living longer and, as a result, require more health care in the course of their lives. At the same time, research and technology are offering more, and more expensive, options for treatment and care.

We are faced with the situation of steadily rising health care costs and growing demand at a time when governments are saying we simply can no longer afford to fund either. The third and most serious threat to medicare in any form is the ongoing reduction in transfer payments from the federal government to Ontario and all other provinces.

Over the past few months we have tried to make it clear that for the upcoming fiscal year, 1992-93, we as a sector need an increase of 8.61%, or $630.7 million, to maintain what hospitals do and how they do it today. That 8.61% does not take into account collective agreements yet to be negotiated with the Ontario Public Service Employees Union, the Canadian Union of Public Employees or the Service Employees' International Union, which taken together represent more than 60% of the staff of the public hospitals of this province.

Using our customary economic forecasting model -- a model with which I think the Treasury and the Ministry of Health would tell you they find favour, at least in this form -- that amount is divided into three components: extraordinary adjustments amounting to 2.05%, or $150.5 million, to cover government-mandated expenditures such as pay equity and the pending new regulations relating to occupational health and safety; Ministry of Health formula adjustments totalling 3.21%, or $235.04 million, and a general economic adjustment estimated at 3.35%, or $245.61 million, to cover identified hospitals' committed costs, such as the collective agreements to which I alluded a minute ago.

That includes only the quantified cost of the 1991 collective agreements with the Ontario Nurses' Association and the Canadian Union of Operating Engineers and General Workers, not CUPE, OPSEU, SEIU or the many other unions representing hospital workers. Every 1% shortfall in the allocated increase next year could represent the equivalent of 1,700 jobs lost or a further 475 beds closed in the system. In addition, OHA can state that for every 1% increase in salaries and benefits for employees covered by collective agreements currently under negotiation, there will be a further increase in hospital costs of $31 million.

This 8.61% is not a wish list that would enable us to do anything new or innovative or different. It simply represents what is necessary in order to continue to provide the same high-quality patient care for which Ontario's hospital system is known throughout the world.

Obviously the government has been equally frank about its own financial plight. The Treasurer has said that it simply is not possible to give us the increase we are saying is necessary to sustain the system in its present form. We understand that. Given our mutual recognition that we are caught between the proverbial rock and a hard place, what is needed is more direction and collaborative planning rather than arbitrary directives to stay within budget regardless of the consequences.


There is a great deal of concern now on the part of hospitals, health professionals, government and the public about how to manage and plan the system. Hospitals themselves are working diligently, in an increasingly turbulent environment, to manage effectively and maintain the quality of the system. Modern management tools of utilization review, total quality management and continuous quality improvement are being used and refined to aid in that process. A new relationship between health care partners is emerging. It has the potential to be a positive one.

The difficulty, from the standpoint of the OHA and its hospitals, is that for several years now we have been in a holding pattern. Hospitals are willing, indeed anxious, to take an active part in reshaping the system, but clear direction from the government is needed.

Hospitals are seizing opportunities to rationalize their services and become more effective in many jurisdictions. Acute care hospitals in the Windsor area have been at the table with district health councils to discuss streamlining services there, by not just cutting beds but possibly shutting hospitals. Because of delays in the development of new and expanded services in the community and delays in the redevelopment and replacement of the existing facilities created by government inaction, the four acute care hospitals in that city are prepared to consider reducing the number of sites from four hospitals with five campuses to two. The co-operation and collaboration of community-based organizations are admirable, but this still amounts to being forced to make health policy decisions in the absence of clear policy and planning direction from Queen's Park.

Community hospitals and their volunteer citizen boards have an outstanding track record of dedication to the public interest. There are now clear indications that the government believes the public interest will be best served by containing health care spending while preserving universal medicare. Hospitals are prepared to do our part, if we could just get the goalposts to stop moving.

By any standard of comparison Ontario's hospitals are well managed. For example, administrative costs for health care in the United States are now fully 117% higher than in Canada, according to a recent article in the respected New England Journal of Medicine. Those administrative costs in Canada actually declined in real dollars between 1983 and 1987 while they went up 37% in the United States during that same period.

Hospitals are managed efficiently, within the limitations imposed on them. They currently have a mandate to meet the needs of their communities for care. The government has taken upon itself a mandate to change the public's perceptions of its needs. Hospitals volunteered to help change those perceptions, and our members are not being given adequate resources to do that, or to meet our primary mandate of delivering quality health care as it is currently defined.

Hospitals have a long tradition of grass-roots community-based development reflected in their governance structure, which relies on boards of trustees or governors who are all volunteers. Hospitals have, without exception, been established to meet community needs.

We must point out that physicians' practices are a major contributory factor to rising health care costs. It should be noted that Ontario spends more per capita on physician services than any other province in Canada. For the fiscal year 1989-90 Ontario spent $441 per person on doctors' services compared to $350 per capita in British Columbia or $288 in Alberta, according to Health and Welfare Canada data. The other provinces spend between $200 and $250 per capita on physician services. If Ontario were to spend only what BC spends, that would mean a savings of $1 billion in the health care system per annum.

The Chair: If I may interrupt, I just want to point out that this is extremely important and so we are going to extend the time, but I am conscious of the fact that there are two other groups to present within a relatively limited amount of time.

Mr Timbrell: I understood the committee sits until 6 o'clock. Is that not so?

The Chair: That is true, but we do want to have ample time for discussion.

Mr Timbrell: I am trying to read as fast as I can and be intelligible, if I can find where I was.

Mr Wiseman: The bottom of page 8.

Mr J. Wilson: You see, Dennis, they are giving you clear direction.

Mr Timbrell: That is right.

That is one of the reasons the cap on physician payments that was included in the settlement last May was so important. That is also why the formal joint management committee with the Ontario Medical Association and the government was such an integral part of that agreement. Hospitals have been identified for years as one of the key areas where health expenditures are concentrated, and yet the less formal OHA/Ministry of Health joint policy and planning committee was created only recently. The next logical step is to have all three parties sit down together to plan the called-for downsizing of the system.

In her speech to delegates at our recent annual convention, the Minister of Health said: "We know that the experts say that at least 25% to 30% of everything we currently do in the health care system `has no proven value.' That's $5 billion in expenditures that the experts say is wasted." We are still waiting to find out who those experts are. Ms Lankin has made a provocative statement based on some research which apparently relates primarily to clinical procedures, not specifically to hospital operating costs. A study of cardiovascular bypass, endoscopy and carotid endarterectomy by the Rand Corp in the US is one of several pointing in that direction.

As former Deputy Minister of Health Martin Barkin said earlier this year: "On average, we are able to say that about 25% of what is done can be validated as absolutely indicated. Perhaps another 30% absolutely ought not to be done, even though it may be well executed. That is, the wrong thing was chosen, but it was done well... As much as 45% falls into a grey zone of decision-making."

Clinical procedures, like those mentioned above, which drive hospital operating budgets, are initiated by physicians. Hospital boards and administrators do not make those clinical decisions, although they are often forced to struggle with doctors over the use of restricted resources. OHA strongly supports the concept of utilization management through which hospitals work with physicians, other health care professionals and management to scrutinize the utilization of resources, comparative lengths of stay, and other measurements to ensure resources are used effectively. But the evaluation of health outcomes of various medical procedures is still in the very early stages of development. It will require the combined efforts of physicians, researchers and others to make progress in this key area.

It must be emphasized that hospitals currently have very little direct authority to control decisions by physicians -- for laboratory work or surgery, for example -- that have an impact on each institution's operating costs.

OHA supports changes to the Public Hospitals Act, which is currently under review, that would mandate utilization management and strengthen hospital boards in monitoring physician practices.

In the mid-1970s there were 53,320 active and chronic beds in the province's public and private hospitals. To put that in context, in 1989, by which point relative to the period I have just alluded to, the population of the province had grown by more than 20%, there were 224 hospitals and about 51,000 active and chronic care beds serving a population of more than nine million. That number has dropped further since. There has been no net growth of hospital beds in that period, despite tremendous growth in Ontario's population.

In a recent survey by the OHA, we found that for the two-year period from April 1, 1990, projecting through to March 31, 1992, a further 3,292 beds will be permanently withdrawn from Ontario's hospital system and 4,329 full-time equivalent staff positions eliminated. Despite these drastic measures, the hospitals project combined deficits totalling $178.7 million for this current fiscal year.

What has occurred on the hospital side has been a paradigm shift, because despite a growing, aging population over the past decade, hospitals' share of the global health budget has shrunk from 48.1% to 43.7% of provincial spending on health care. Hospitals have in that time found new and innovative ways of providing care to the growing numbers of people who come to emergency departments or through other channels for the care that rightly or wrongly they have come to want and expect.

Three important planning documents were released in 1987: Toward a Shared Direction for Health in Ontario, Health for All Ontario, and Health Promotion Matters in Ontario, known respectively as the Evans, Spasoff and Podborski reports. Those documents all called for shift in emphasis from treatment of disease to prevention of illness and promotion of health.

Like Building Community Support for People: A Plan for Mental Health in Ontario, they stressed that creating adequate community-based resources was a prerequisite to downsizing the institutional sector. But hospitals have been forced to deal simultaneously with pressure to downsize and to shift their focus, providing traditional care and community-based services without any ability to plan fully for even the current fiscal year, let alone for the longer term.

A 1988 Coopers and Lybrand Consulting Group survey of hospital CEOs and chief nursing officers found that "74% of all respondents felt that the development of long-range strategic plans for their hospital within the context of government initiatives and directives was one of the five key future health service delivery issues."

The Ministry of Health's 1973-74 annual report noted that the guideline for active treatment beds was reduced from five per 1,000 to four per 1,000 population, and later in the 1970s it was further reduced to 3.5 per 1,000 population. Those guidelines have been reduced further, but with the freeze on new beds there are no minimum standards or guidelines today for an appropriate number of hospital beds or, for that matter, beds in nursing homes or homes for the aged either.

We can accept that smaller is better, but there has to be a limit to that philosophy. That is the message hospitals and trustees have been waiting to hear. At what point will cuts jeopardize the quality of care? In Ontario, we talk about having one of the highest rates of institutionalization of the elderly, without making a distinction between hospitalization or other forms of institutionalization. Without some goal in mind, we are shooting for a target that has yet to be defined.

The provincial government's consultation paper, Redirection of Long-Term Care and Support Services in Ontario, has now been released. For several years, the ability of hospitals providing chronic care to plan for the future has, in fact, been paralysed. The reform is needed because of changing government priorities but, in the meantime, hospitals and patients have suffered because of the slow pace of change.


The long overdue Chronic Care Role Review, an integral part of the redirection process, is still not off the ground. Meanwhile, the announcement last June by yourself, Madam Chair, in your former capacity as Minister of Community and Social Services, that a minimum of $37.6 million will be reallocated from hospital budgets to the government's care and support services division over the next five years has apparently been superseded. The recently released consultation paper states that after five years a minimum of $37.6 million would be reallocated every year. We are seeking answers from government on this unexplained change.

More than 150 of the hospitals in Ontario offer a range of chronic care services, and every acute care hospital has its share of patients inappropriately occupying acute care beds. OHA is committed to ensuring that the new system functions as well as possible. That seems to fly in the face of the plan to redirect long-term care, with its built-in assumptions. Those assumptions, incidentally, are not confined to hospitals. They also extend to removing home care from the jurisdiction of public health units over the next three years.

Hospital funding has been in a state of flux for some years now. It has been in a holding pattern or reduced relative to overall health spending, while costs are escalating and hospitals take on more and more responsibilities. That is why there are hospital deficits. But as a sector, we have also been presented by default with the problem of rationing care, of making ethical decisions about who should get what kind of care. We do not want to see those decisions made solely on the basis of balancing budgets.

The OHA's annual survey of public attitudes towards health care and Ontario's hospitals has been pretty consistent year after year. The people of this province are happy with the existing familiar health care system. The message identified in the Environics poll this year was that hospital spending should be the government's top priority, even above environment or education, and 86% of those polled said hospitals should not have to lay off staff, close beds or reduce services to balance their budgets.

In reporting this, we are the messengers. We understand that the government simply cannot afford to make its decisions based on public opinion, and we are doing our best to be responsible. OHA is working with government to address issues through the joint OHA/Ministry of Health policy and planning committee. Hospitals are working with government and district health councils to get a break-even budget point for this year and for next. Hospitals are changing, and changing very, very quickly. They are funding new methods of care and are active in health promotion.

OHA's Report on Health Promotion, completed in July, found that most hospitals fund health promotion activities out of their global operating budgets. Out of 186 hospitals that responded to the question, "Are you experiencing any obstacles in the implementation of health promotions/activities at your hospital?" 146, or 78.5%, answered yes. The three major obstacles to providing programs and activities for inpatients, outpatients, communities or employees are (1) lack of funding, (2) lack of adequate staff, and (3) lack of facilities.

Whose obligation then is it to reshape public attitudes towards health care -- the government's or hospitals'? The message we get from the public is clear. The financial message we get from government is clear. And frankly the two messages are incompatible. We understand the need for change, and the firmness of the government's resolve, and we have been saying we will help you get there, if you will only tell us where you want to go.

At the same time, we are caught between providing what the public wants and what the government is willing and able to pay for. And hospitals have been given the additional responsibility of either changing the public's expectations of the health care system or simply changing a system that the public is happy with.

We have accepted the message that medicare, as it was first established, is no longer affordable. And while we find commendable the Premier's proposal to have a social charter included in the Constitution, if all it does is to enshrine an underfunded, underserviced system, the words of the charter will have a hollow ring indeed.

What we require is a contemporary vision of accessible, portable, universal, comprehensive and publicly administered medical care that is also affordable and that we can work together to create. In the meantime the system is slowly eroding. We will continue to do everything humanly possible to shore it up. But clear vision and direction from government are badly needed, and needed now. We cannot do it alone, and we cannot be all things to all people.

The Chair: Thank you, Mr Timbrell, for that most comprehensive presentation.

I now ask the Registered Nurses' Association of Ontario to make its presentation.

Mrs Edwards: My name is Joan Edwards, and I am a registered nurse and a board member of the Registered Nurses' Association of Ontario. I am also the chair of the association's provincial finance committee.

It is a pleasure to be here today to participate in these pre-budget consultations. For your reference, Madam Chair and committee members, the presentation I will be making today is included in the red folder in front of you.

The Registered Nurses' Association of Ontario is the professional voice for registered nurses in Ontario. The association protects the profession's interests and integrity, while it influences and reflects changes in the profession and in the health care system.

RNAO promotes professional recognition of registered nurses and lobbies government and other organizations on issues that affect the wellbeing of nursing and client care. Membership is voluntary. Our membership represents every aspect of registered nursing in Ontario, from student to retired nurses, and includes staff nurses in the community and institutions and nurses in research, education and administration.

The RNAO, like you in government, is very concerned that decreasing federal transfer payments threatens the ability of the province to provide the five basic principles of health care. We have joined with six other partners through the Canadian Nurses Association to participate in the Health Action Lobby, know as HEAL. RNAO members have lobbied members of Parliament and expressed the concern that health is not addressed in Shaping Canada's Future Together. HEAL information is included in the red folder I brought for you.

Today I will be addressing two key areas of fiscal concern for the RNAO. They are, first, health human resources planning and, second, reallocation of funds.

On health human resources planning, the RNAO believes in the appropriate level of care giver with the appropriate education serving the client. In the 1988 Meltz report, commissioned by RNAO, emphasis was placed on the necessity and importance of long-range co-ordinated manpower planning. We continue to believe there has to be better co-ordination between Ministry of Health planners, the health professions, employers and the Ministry of Colleges and Universities.

A proliferation of minimally educated individuals will not serve the best interests of Ontarians. In our current economic environment, had an independent institute for co-ordinated health manpower planning been developed, as recommended in the November 1988 Meltz report, the four groups just mentioned would have been able to anticipate, at least in part, our current situation and to proactively plan our human resource needs. As well, human resources planning, linked with the trend for increased care delivery outside the traditional institutional setting, would have prepared care givers for the changing demands of community practice.

The preliminary draft of the Orser report, entitled Working Together to Achieve Better Health for All, mentions substitution as a way to improve cost-effectiveness and quality of care, as well as to increase job satisfaction for the professionals involved. We would support using some of the substitution techniques outlined in the Orser report in individual health care settings. We do not advocate applying these techniques carte blanche across the province.

RNAO continues to believe in the appropriate level of suitably educated care giver to provide services. When the professional component is excessively diluted with less-educated and lower-cost personnel or volunteers, the quality and safety of client care may be severely compromised. For example, it may be completely safe and mutually beneficial to have a grandparent program for children, whereby older adults provide socialization, nutrition and mobilization assistance to children. But it would be courting disaster to have non-professionals assess and provide ongoing care and assessment for an acutely ill child.

Substitution provides an opportunity to free professionals to more appropriately use their skills and talents. However, substitution must not be a method whereby professionals are spread so thinly across the province that those who remain become totally frustrated with their inability to safely meet client needs, and subsequently leave health care to work in other industries.


The second issue I would like to address today is that of reallocation of funds. RNAO is supportive of reallocating funds throughout the health care system. Involvement from nursing groups regarding the decisions surrounding reallocation of resources and funds is essential for maximum outcomes. The measures described by Mr Laughren in his November 19, 1991 statement to the Legislature have direct applicability to, and can be implemented among, health care organizations, institutions and professions. Freezing the purchase of non-patient vehicles and furniture and avoiding cosmetic building enhancements is a direct example, as is reducing and deferring capital spending. Moneys saved and interest earned in these areas avoid direct patient care cuts.

Duplication of services needs to be stopped. Cities and towns in close proximity, which have capital equipment operating undercapacity, is a waste. Having technicians and professionals waiting for clientele is a waste; yet other centres are overloaded, staff harried and clients disgruntled with the level of care and service provided. Balancing the workload across the system through rationalization of services and portability of employee benefits is one way to decrease the wastage and enhance care.

Utilization review must be taken seriously by health care providers and by consumers. Wise assessment needs to occur first to avoid a shotgun approach to laboratory testing, radiographic examination, drug prescriptions and interventions. Clients need assurance that their particular health care needs can be addressed without having every test the facility has to offer. Alternatively, humanistic decisions need to be made with compassion for those individuals with terminal diagnoses. Providers and consumers need to avoid interventions which are purely academic or only prolong dying, rather than maintain or enhance living.

Education of providers and consumers is essential. Once again, savings gained here avoid cuts so that efficacious patient care is provided.

Our society has become increasingly litigious and consequently many health care providers seem to practise law along with medicine. A case in point is the situation where a terminally ill individual was transported by ambulance from one institution to another to confirm his diagnosis. The diagnosis was confirmed, and the client died on the return trip. The cost of the trip and the consultant's fees are minimal compared to the patient's loss of dignity and the family's grief. Why was this trip made?

RNAO represents a wide range of registered nurses throughout the province. Issues which are more focused and reflect the concerns of constituent groups within the association have not, in the interest of time today, been addressed. These issues include, and are not limited to, pay equity; long-term care; occupational health and safety, and workers' compensation. To best represent our collective membership, we have chosen to focus our presentation on the two issues, health human resources planning and reallocation of funds.

In summary, RNAO is supportive of provincial government action to retain and increase federal transfer payments. Our two main points today are:

1. Health human resources planning: The appropriate fit of skills and education among care givers with clients in the most realistic setting will ensure continued quality health care.

2. Reallocation of funds: Serious review of operating and capital expenses will allow for reallocation of funds from non-patient or client care uses to direct patient/client care delivery.

The Registered Nurses' Association of Ontario appreciates the opportunity to participate in this budgetary process. We welcome further interaction with this committee and government to clarify or expand on today's presentation and discussion.


The Chair: The Ontario Public Health Association.

Mrs O'Donnell: Good afternoon, Madam Chair, committee members. My name is Ruth O'Donnell. I am the president of the Ontario Public Health Association. Presenting with me are Audrey Danaher, who is the chair of our public policy and resolutions committee, and Peter Elson, who is our executive director. We do appreciate the opportunity to present our brief to this committee with the other deputations on health care.

For those of you who may not be familiar with us, the Ontario Public Health Association is a voluntary association of approximately 3,000 members, people who are involved in community and public health in Ontario. Our mission as an association is to strengthen the impact of those who are working in community and public health. We do that through advocacy, education and public awareness, among other things.

We are trying to focus our brief today on an investment in the creation of health. I believe you have a copy of our brief. An investment in community and public health is an investment in the future health of Ontarians. It is an investment in health protection and health promotion. It is an investment in keeping Ontarians as healthy as possible for as long as possible in the places where they live and work and play. We believe that this investment in prevention will pay dividends in a reduced number of accidents at work, on our highways and in the home. We believe that an investment in health promotion will support and nurture healthy communities, healthy environments and healthy lifestyles. Basically, health promotion is an investment in the creation of health.

We would like to make the point that investing in community and public health is not the same as investing in health care. Treatment and care is a little bit like term insurance: It works only when you need it. On the other hand, accident and disease prevention and health promotion are like a retirement savings plan that helps people to remain healthy and productive longer and to be active participants in the lives of their communities.

Ms Danaher: A systematic change in the allocation of resources for health in Ontario must take place. OPHA calls on the government of Ontario to reduce overall institutional and drug benefit costs by 3% in 1992-93. This would represent a saving of $312,400,000.

We call for a reallocation from the following programs:

The drug benefit program: OPHA endorses the opinion of health policy consultant Michael Rachlis, the Provincial Auditor, Douglas Archer, and the Lowy inquiry that there are a number of ways of curtailing and capping the rising costs of the Ontario drug benefit program. These would include such things as rolling back price increases on drugs, eliminating the 10% surcharge on direct sales from manufacturers to pharmacists, reducing dispensing costs by setting prescription renewal guidelines and negotiating lower drug purchase costs through the economy of scale. This would result in an estimated saving of $76.9 million. Ontario must take advantage of its combined purchasing power to reduce pharmaceutical costs, and dispensing fees must be minimized by extending the length of standing prescription orders.

The quality of treatment by medication can be improved by improving prescription practices, physicians' knowledge of pharmaceuticals and the recognition and use of the pharmacist as part of a multi-disciplinary decision-making team.

Regarding hospital expenditures, OPHA calls for a 3% reduction in hospital expenditures in 1992-93 from 1991-92 expenditure levels. This represents $235,500,000.

The Ministry of Health must show clear and unequivocal leadership in the reduction of payments to hospitals. Further, this leadership must extend to an explicit indication of how these cutbacks should be made. Across-the-board reductions are not acceptable. Rather, they should be made in the context of relevant community need and overall resource assessments.

Cuts should start with the corporate structure and the reallocation of services based on demonstrated need, not supply-side economics. To reduce staff and nurses is to cut the wheels off the engine without adjusting the generator. Physician utilization of hospital services and unwarranted procedures must be scrutinized.

OPHA shares the concern expressed by the minister in her address to the Ontario Hospital Association: "We know that the experts say that at least 25% to 30% of everything we do in the health care system `has no proven value.' That's $5 billion in expenditures that the experts say is wasted." This issue is too important and too expensive for the government to maintain a third-party relationship with health institutions. A viable partnership must be established which provides a means of prudently downsizing and rationalizing hospital use. We agree with the Minister of Health in her recent call for a Ministry of Health/OHA committee to be struck.


We are also mindful of the extensive recommendations of the report of the British Columbia Royal Commission on Health Care and Costs, entitled Closer to Home. Among its many recommendations is included that "there be an annual global cap on payments to physicians by the medical services plan. This cap should be adjusted for changes in population and the general price level, but should not respond to increases in utilization or be adjusted for changes in `technology' or other essentially unquantifiable factors."

The situation in which we find ourselves is not just a financial crisis; it is a systemic watershed. The current system cannot be contained.

A community-based discussion on the appropriate use of hospitals, practice guidelines and the present patterns of use and the overall policy of moving people and resources out of hospitals is fundamental to acknowledging and supporting this necessary and sometimes painful systemic change. Community consultation and education regarding the definition and determinants of health currently under consideration by the Premier's Council on Health, Wellbeing and Social Justice are critical prerequisites to public support for a more equitable distribution of public resources.

We remind you that for any cutback in the hospital sector, criteria must be established for how these cutbacks are made. Community and care giver support services bear the brunt of any hospital service cutbacks. Therefore, community consultation must become an integral part of planning for all service changes.

On November 20, the Minister of Health told the Ontario Public Health Association:

"We find it is the most cost-effective strategy to rally our strength and staff around community-based public health measures. It's better to protect and defend the population before an epidemic breaks out and hundreds of thousands in the community are dispatched to expensive hospital beds for treatment."

I put it to you that we have an epidemic of tobacco, alcohol and drug use, which places a phenomenal burden on our sick care system. We have an epidemic of preventable accidents. We have an epidemic of unnecessary medical procedures, such as caesarian sections, tests and drugs which add unnecessarily to our costs. We have an epidemic of premature deaths due to lung cancer, impaired driving and battered and abused citizens of Ontario.

OPHA fully supports current cutbacks in out-of-country fees and laboratory services and recommends further limits for criteria to reduce and eliminate unnecessary tests and procedures. Meaningful, equitable partnerships working together -- hospitals, community, community health service providers, unions -- are the key to systemic change.

Mrs O'Donnell: The second recommendation the OPHA places before you is to proceed with the implementation of the Mandatory Health Programs and Services Guidelines, which were in fact a government document passed originally in 1985 and revised and endorsed in 1989. It will require $60 million in program funding in 1992-93 to fully implement the mandatory standards established for Ontario's 42 official health units.

These mandatory standards are designed to meet four goals: that Ontarians will have the opportunity to attain an optimal level of physical, mental, emotional and social development appropriate to their life stage; that all the people of Ontario will have the opportunity to adopt and maintain health promotion practices for themselves, their families and the community; that communicable disease will be reduced or eliminated; and that the community itself will be a health-supporting environment in which people will be protected from adverse health consequences of exposure to toxic, hazardous substances and conditions in homes, public places and the workplace.

The third recommendation is a clear definition of the responsibility and accountability for public health. The mechanism in place for financing these provincially mandated programs through cost sharing with local and regional governments is presently a barrier to full implementation of the core mandatory services.

I think the buzzword these days is "disentanglement," which is currently the subject of discussions between the Association of Municipalities of Ontario and the government of Ontario. This is a matter of utmost concern to the OPHA and it must be addressed. Political and fiscal accountability for public health must be resolved. If the current situation continues, implementation of the mandatory programs and services will be slowly strangled by ever-decreasing municipal dollars.

Mr Elson: The fourth recommendation is to improve and expand community health centre services.

Some $65 million is needed in 1992-93 to improve and expand community health centre services. Community health centres provide a crucial integration of clinical, prevention and promotion services. Community health centres are an important reflection of community support and a commitment to defining health in a broader context. Planned expansion of community health centres should be supported and existing centres must have the capacity to respond to their community needs.

Recommendation 5 is for implementation of long-term care reform. Four hundred million dollars is needed in 1992-93 to implement long-term care reform in Ontario.

OPHA fully supports the long-term care initiative and wishes at this time to bring your attention to the need for support for informal care givers, the hidden support network within long-term care. OPHA calls on the government of Ontario to recognize the financial burden carried by these individuals and to provide a mechanism for direct subsidy and/or support credits.

Recommendation 6 is to give kids a chance: fight the tobacco epidemic.

OPHA calls on the government of Ontario to increase tobacco taxes by 3 cents per cigarette or $6 per carton as one component of an eight-point comprehensive tobacco strategy to reduce cigarette consumption by children. This is a campaign which is supported not only by the the Ontario Public Health Association but also by a number of other tobacco-cessation-related organizations. The net increase in tobacco tax revenue is estimated to realize $400 million. That takes into account the decreased consumption levels.

Relative to other provinces, Ontario is in danger of having the most affordable cigarettes in Canada. Research has shown that a 10% increase in the price of tobacco will result in a 12% reduction in cigarette consumption by teenagers and a 4% reduction by adults. One third of all smokers sustain a smoking-related illness, with tremendous human, productivity and health care costs. This was reiterated in the recent Tobacco and Health report released by the chief medical officer of health for the province of Ontario earlier this month.

Mrs O'Donnell: In conclusion, I would like to call your attention back to our original statement that our major concern is with the creation of health investment in the creation of health. The cost of not making these investments will be a health cost profile which will continue to be uncontrolled. It will be driven by supply, not demand, by technology rather than human need, by sickness rather than health and by institutions instead of communities. Thank you very much.

The Chair: Thank you very much, all of you, for your presentations. I am sure the members will have questions they wish to ask. I might add that you should feel free to refer any questions to any of the staff or other colleagues whom you have brought with you. I will begin with Mr Sutherland.

Mr Sutherland: It is a pleasure to have all the groups here today. It is interesting and we have heard some diverse comments. I would certainly think that all of you are very sincere in your concern about delivering effective health care in this province.

I want to pick up on a point that came out of this morning's discussion regarding my riding. We had the teachers' federations talking about services that had been cut by the board and, more particularly in my riding, speech services. I commented at that time that it was quite interesting that when I had a meeting in my riding trying to solve this problem, a director of the local hospital said it was the first time in 11 years that all the players who were providing speech services to school-age children had been in one room together to talk about that.

Bringing it more in tune with the presentations we heard here, Mr Timbrell, you talked about the public health mandate or health education mandate of hospitals. We know we have the public health and that nurses are involved with that, particularly the registered nurses. I guess what I want to know is, where is the co-ordination of the services when you take specifically that area of health education or accident and disease prevention? I am not clear on this. Who is directly responsible for it, or are all of you responsible for it? How do you co-ordinate all your activities?


Mr Timbrell: One of the reasons we have district health councils in the province -- they have now existed for about 16 or 17 years since the first of them began -- is to bring to one table all of the players, if you will, in the health care system, whether they be in the public health sector or the providers or the consumers or the trustee or the administrative side of the institutional sector. It has always been the intention -- to be honest, I am not sure it has worked uniformly well across the province -- that this is the mechanism.

That does not always bring in the social service or the educational or the other voluntary agencies. You might as well ask, where was the hearing society? Where are some of the other voluntary groups? They are out there as well. But there is a mechanism. Mrs O'Donnell is a former member of the district health council for the county of Brant and she could perhaps add to that.

Mrs O'Donnell: My comment, before I speak to the health councils' role, is that I feel each of us and each of our associations represents people who have a mandate in different parts of health care. The primary mandate for health protection/health promotion rests with the official public health agencies. The primary responsibility for treatment, diagnosis and health care rests with the hospital sector.

I feel it is important that we co-ordinate better than we have done in the past in order that we are not attempting to duplicate the services that one of the others does better. The health councils are providing that kind of co-ordination in our communities. I also feel there is something else happening that is being promoted from our Ministry of Health, and that is to try to get the attention to some of these health services moved into other community-based components. I would pick the community health centres as a perfect illustration of a co-ordinated service centre where the diagnosis and treatment of illness are provided, as well as there being a health protection/health promotion component, moving into health lifestyles promotion. I think we can move towards a more co-ordinated effort as we try to hone the system a little more and make it more fine-tuned than it is now.

Mr Timbrell: I just want to add, in answer to Mr Sutherland's question, that this is one of the reasons we are concerned about the apparent intent of the Ministry of Health to force hospitals and some communities to stop being the administrators of home care programs or home oxygen programs, ambulance services in other communities, to force the public health units out of the provision of home care services. At a time of fiscal necessities and the need for the system to be better co-ordinated, this is no time to start driving it further apart.

Mr Sutherland: Could I get some comment from the Registered Nurses' Association of Ontario?

The Chair: Certainly.

Mrs Sullivan: Did the minister not just do that, suggest that public health authorities should not be involved in the delivery of long-term care?

Mr Timbrell: That is the point I am making, that the ministries are in our view inappropriately trying to compartmentalize at a time when there is, if anything, a need for more co-ordination and more co-operation, not less.

The Chair: Would you like to comment?

Mrs Edwards: Certainly from our perspective, we see our role and our mandate not in terms of global facilitation of co-ordination, but more on an individual client level of ensuring that available resources, both institutional and in a wide variety of community agencies and settings, are co-ordinated and brought together for a particular patient or a particular client.

Mr Sutherland: May I ask one more question?

The Chair: Very briefly.

Mr Sutherland: Thank you. We also had quite a range in terms of where health care funding should be going in the next budget year. The hospitals were saying we should put in -- I believe it was 8.6% that you have in your document here. The public health association said that, if anything, it should decline. Given the nature of the tight fiscal situation, and the fact that everyone is concerned about health care, I would like comments from each of you on how we manage the change that is going to be occurring in the health care system. I think we all agree that change has to occur. Maybe this is more supplemental to my first question: How are we going to manage that change? We said we have to co-ordinate better than in the past. What steps are in progress right now from your organizations that are helping to facilitate that change, to facilitate better co-ordination than we have had in the past?

The Chair: Is that question directed to --

Mr Sutherland: All three.

Mr Elson: On behalf of the Ontario Public Health Association, I would like to mention two particular initiatives that we have under way at this time. Earlier this spring we had a provincial workshop on creating linkages among hospitals, community agencies and public health units. That was attended by almost 100 individuals from hospitals and community agencies. As a supplement to that, every single delegate at that conference indicated he or she would be prepared to participate in a local forum to address the issue of what kind of relationship currently exists among those three sectors and what needs to be put in place to help it become a better working relationship, independent of a particular issue that would have to be dealt with.

We are negotiating at the present time through the Association of District Health Councils of Ontario to identify three or four pilot communities that would be interested in engaging in such a process. That is one particular initiative that we have.

Mrs Edwards: The RNAO sees itself as a facilitator and as a link or a bridge between the needs and beliefs of the institutional setting and the needs and beliefs of community settings. We do not see a particular functional role for ourselves in terms of setting or determining policy in changing the allocation of health care spending. Our mandate is to support the need for providing a health care provider who has the appropriate educational and experiential preparation to provide the care that is required in either an institutional or a health care setting.

An example of that is the much earlier discharge of patients from an institution to the community and ensuring that the providers, those professionals and others who are caring for those individuals in the community, have the appropriate preparation and experience.

Mr Timbrell: I wanted to say a few words about change. When we sit and talk about change in the health care system, it amazes me that the expressions of interest on this issue either assume that there has been little change or that we are starting from zero. I guess, like Mr MacFarlane and Mrs O'Donnell, I have been involved in health care for a lot of years. I can remember when hospitals represented about 52% of provincial government spending on health care, and it is now just over 43% of provincial government spending on health care. In the last decade provincial government spending on everything from public health to drug benefits to out-of-province claims to OHIP and on and on and on went up as the proportion of provincial government spending on hospitals went down.

When we talk about change in the hospital system, we are not talking about something theoretical or something that may happen next week, next month or next year. It is happening today. In the last decade, while the population of Ontario went up 20%, the number of services provided in hospitals on an outpatient basis and in the community in either hospital-based outreach programs or community-based programs run by hospitals went up almost 100%. When we talk about reducing the relative levels of spending on hospitals, I am sorry, but the reality is that you do that and we have to accelerate the rate of change. For us, change means closing more beds and letting more staff go.

There was a suggestion here today that we could cut the 1991-92 allocations by 3%. The 1991-92 allocations started the fiscal year being a full five points below what the system needed just to maintain what it had a year ago. By the time the budgets were submitted by the hospitals, they had already worked out of the system about 2.5% of that gap, and the only way you work it out is by tightening further, leaving 2.5% still to be dealt with in the current fiscal year. Then you add to that the 8.5% we are projecting is required next year, not for any additions, not for any embellishments, but just to pay the negotiated contracts with ONA and CUPE and deal with the ministry's own mandated formulas and the government's mandated programs. That is a 14-point gap. We know from managing the system that this is about 24,000 more jobs and about 6,650 more beds in one year that would have to come out of the system.


Ms Danaher: I think we have to be clear that beds do not equal health care. People are interested in the basic determinants of health, the things that create health: adequate housing, adequate income, adequate nutrition, a positive lifestyle. Health is not medical beds, and we have to take, I think, a very firm stand on that. We want to prevent people from getting ill, not deal with them when they are in need of high-level, expensive care. It is better for the people of Ontario and it is, as well, more cost-effective. Health care embraces a very broad concept and I think we have to really keep that in mind. We have to take a firm stand in making these cuts.

The Chair: Thank you, Ms Danaher. We will move the questioning on to Mrs Sullivan.

Mrs Sullivan: Thank you, Madam Chairman. As you know, this is a new approach to dealing with pre-budget consultation and while I think it is valuable to have the three groups together, we may in fact be a little short of time in terms of the number of questions we want to get on. I hope the Chair will bear with me.

The Vice-Chair: Just before you begin, I think what we will do is try to keep rotating,, so there may be an opportunity to ask a second or third question.

Mrs Sullivan: Are you saying I can ask only one question of one organization then?

Mr J. Wilson: Ask a long one.

The Vice-Chair: No, you can ask questions, but I am saying we will keep trying to rotate. Okay?

Mrs Sullivan: Okay. I have questions that are specifically budget related -- which is why we are here -- for each of the three organizations, and I think it is important that they be on the table.

I am interested in the public health association's recommendation of a 3% reduction in hospital expenditures for the next fiscal year. I wonder how you reached that conclusion and how you reached the conclusion that it could be done without reducing staff and nurses, which, as you say, is to cut the wheels off the engine without adjusting the generator, when 70% of hospitals' costs are staff costs. In fact, the savings which you suggest would be accrued by that decision do not necessarily mean savings in the end, because facilities or services would have to be put into place in another setting. Could you respond to that?

Ms Danaher: Yes. Services do have to be put into the community if you are cutting costs in the hospital sector; otherwise you are going to have a situation such as when psychiatric hospitals were closed and we had patients dumped in the community because there was inadequate support. You have an initial situation where you have to cut costs, but because you are doing preventive work, you will get savings in the end.

The other point is that the group costing the system a lot of money is physicians. Physicians received a very substantial increase in their salaries this year, and you are right, I do not think this should be on the back of nurses or other health care providers. Physicians are the ones prescribing drugs and treatment and expensive tests and that is where there is a significant overlap in services. I think that situation needs to be addressed. There is also an oversupply of physicians in this province. I think that needs to be looked at as well in terms of cutting the numbers of places in medical schools, for example, and reducing physician admission privileges in hospitals.

Mrs O'Donnell: We realize the change that is proposed in health care cannot happen overnight; it cannot happen in one year. It is going to take a long time to turn around the system that has conditioned our population to regard the hospital as the place to go whenever there is any health care need whatever. What we feel has to happen is a complete change in the style and the method of delivery of health care and that we reserve our hospital services for the people who truly need them most desperately. It should be where the severe, acute care patient must be looked after. We have already started in the health care system. I agree with Mr Timbrell that there has been a lot of change already established and we have started moving people out of hospital, earlier discharge, having care in the community, recognizing that many things can be done on an ambulatory basis. My hat is off to the hospitals for what they have accomplished there. I think they have done a marvellous job. It is just that we have to do a great deal more than has been done to date.

One of the issues in terms of hospital usage has to do with the gatekeepers of the hospital and I endorse my colleague's point that admission to hospital is medical. Only a physician can admit a patient to hospital and discharge a patient from hospital. We have to change some of those practices. If it has to be done by reducing the budget, it may be the cart before the horse, but that is the only way we are going to make true change in the system and stop using the hospitals the way we have been doing.

Mr MacFarlane: The hospitals are very much community resources. They are not just institutions providing bed-based care. There is a lot of outpatient care in hospitals. Hospitals have used their global budget resources to expand into their communities to help provide care that the other sectors have not funded. I would like to point out that alternative services such as those being suggested are not necessarily less costly services either. It is virtually impossible to provide 24-hours-a-day care in a home setting at less cost than in a hospital setting.

Mrs Sullivan: I have a question of the Ontario Hospital Association relating to allocations for next year. I am going to do a preamble, so you may want to expand upon parts of it.

The Minister of Health has said there is $5-billion worth of waste in the system. To my knowledge, she has not identified where that waste is or what standards she feels ought to be put in place to ensure that waste is eliminated.

None the less, we know that hospitals have certainly had a very difficult time this year with the number of bed closings that we have been seeing. We also know that transition funds for this fiscal year have not flowed; that pay equity funds have not flowed yet for this year; that the pay equity and other government-imposed costs, not only from this government but of course from the past government, have not been met completely in this year's transfers. Those pressures will continue, but there will be an additional pressure next year relating to the Workers' Compensation Board increase.

There may also be some increased pressures relating to the cap on doctors, in that hospitals, to ensure services, may have to make specific arrangements with doctors themselves for those services. We also know the Treasurer went before the OHA and indicated that transfers would be lower this year than last year. If those transfers are perhaps at the inflation rate or 1%, 2% or 3% above inflation, which appears to be some of the general hinting that is occurring, how will hospitals cope?

Mr Timbrell: Right now, all hospitals are involved with their district health councils and with staff of the ministry in reviewing, in some cases, recovery plans for this current fiscal year and, in all cases, starting to examine the budgetary requirements for next year. I wish I had heard rumours that we were going to get inflation or thereabouts. In fact, the rumours we keep hearing are in the order of 2% increases.

Mr Phillips: Probably about 6%, I would think.

Interjection: Between 0% and 3%.


Mr Timbrell: At any rate, I have not heard those rumours. I guess it leads to a very critical point and that is, we need to know well before the start of the fiscal year what the allocations are.

In February of this year, the Treasurer announced an overall increase in spending for hospitals of 9.5%, of which 6% was for an inflationary adjustment. The other 3.5% deals with transitional funding issues of growth and equity and support for life-support programs and small hospitals and on and on, plus pay equity. We do not have the details even yet, and we thought we would have them this week. We were just told this morning it will probably now be mid-December before we will have the final allocations. That is no way to run a railroad, two-thirds of the way through the fiscal year. It is better, mind you: Last year the hospitals got their final allocations on April 2; in other words, at the beginning of the next fiscal year. So it is an improvement by a few months, but a marginal one.

We keep saying, and I think the Minister of Health and the Treasurer understand, that we want to be responsible managers. We want to do it as well as we can, but if you do not give us the tools, if you do not give us the information until almost the end of the fiscal year, how the devil are we supposed to effectively operate what in most communities is one of the largest businesses or employers in that town? We cannot, is the short answer.

Mr J. Wilson: I would like to begin by saying this is a very strange process. I am not a permanent member of this committee, but I am the Health critic for the Ontario Progressive Conservatives, and to have three groups in a row without questions, three groups with at times diametrically opposing views, is a very strange way of doing things. It leads me to believe that --

Mr Wiseman: It was his idea.

Mr J. Wilson: Whose?

Mr Wiseman: Norm Sterling's.

Mr J. Wilson: Well, Norm sometimes has some very bad ideas and I will be chatting with him about that, because I think it plays right into the sort of divide-and-conquer strategy that the government is conducting. You will notice, when I asked the minister in the House today about the hospital bed closings and the overall comprehensive plan, her answer was that we are all scaremongering. This government has done an excellent job, and I have seen it today: the public health nurses against hospitals, against administrators.

I assume your brief refers to renovations done by administrators and that sort of thing. It reminds me of people picking on MPs' salaries, which will not in any way control the federal deficit one bit. You want to take money from the institutional side of the equation. Where is the mention in the brief about nurses and the fact that a full cheque was not sent to the hospital boards to pay for pay equity, yet the minister got credit for it? She also got credit for nurses' salaries but did not send the cheque. It is downloading. I am surprised at the restraint you have shown in the language of your briefs.

Having said that, I hope you realize -- and every day we ask her questions -- she is talking in the House today about the monitoring of the system of hospital beds that the auditor talked about having nothing to do with the cuts in beds. It is the most amazing answer in the world. She is dividing and conquering the health care community, and yet at the same time she sets up these wonderful committees saying how co-operative everyone is, and every day we hear that everybody is working together. That is just not true. It is a bunch of baloney.

The Vice-Chair: Mr Wilson, are you coming to a question?

Mr J. Wilson: I do not want to read the newspapers any more, about one health care group pitted against another, when the blame rests with the government and the lack of a management plan. But having said that --

The Vice-Chair: Mr Wilson, I have been lenient in allowing you a preamble. Could you please place a question.

Mr J. Wilson: Sure. Having said that, I have a dozen questions. What I would like to know, if it is possible in a clear statement is, what do you need from the government in terms of clear direction? We have heard Mr Timbrell and, I think, each of the groups talk about it. What exactly do you need at this point in history in terms of clear direction? What should the goalposts be, and the new standards?

The Vice-Chair: Maybe we could start with the nurses' association and then --

Mr J. Wilson: Maybe you should start with Mr Timbrell, because I am using his language.

The Vice-Chair: I was just trying to rotate it by organization.

Mr J. Wilson: Now that we have you all divided and conquered, we have to decide what to do.

Mrs Edwards: I will move forward then, because I do not feel, from our perspective at least, that our goal is to come here today to divide and conquer. I think very much, and I speak for the RNAO's perspective, our goal is to ensure that we are able to provide a level of care -- obviously from our perspective we are focused on nursing care -- that is appropriate for the type and nature of client need, and we are not wishing to make jabs at or take sides with either the community-based agencies or institutions, because we provide a professional level of care across all of those.

I certainly hear what you are saying in terms of lack of financial support for issues that have had major financial ramifications in both institutions and the community and certainly on nurses. However, in terms of what it is we are looking for, we are looking, from a non-financial perspective, for the work we are doing with OPHA to promote and support the position of the nursing profession within the health care environment; certainly the work we are doing, as many other women's groups are doing, with respect to pay equity. And we are looking for a clear delineation, as I mentioned in our brief, regarding substitution in terms of being able to provide an appropriate level of care for patients, for clients. We view ourselves very much in many ways as a bridge.

Mr Timbrell: Essentially I think, from the perspective of hospitals, we need to have some clear indication from government of the level of services it is prepared to pay for, and that can be expressed in several ways. At one time it was expressed in terms of so many acute-care beds per thousand population. In the early 1970s it stood at five beds per thousand. That went down to four beds per thousand in the mid 1970s. By the late 1970s it dropped to 3.5 beds per thousand, and in recent years there has been no standard at all. It has been everybody for themselves. Now, with the more recent development of things like resource intensity, weights and others, it is now more common to talk of so many patient days per thousand population.

Once a reasonable standard is posted, you work back from there, region by region, on the implications that has for the distribution of various services in and among hospitals at the primary, secondary and tertiary care level, and the implications that will have for rationalization and maybe the closure of some hospitals. In the end, you are right, no minister can escape the ultimate responsibility for the decisions, but also no minister can escape the need to establish a framework in which the objectives are clearly defined and we all know what we are working towards. The way it is now, there are no such standards, there are no clearly defined sets of goals or objectives and it is very much every hospital for itself and every community for itself.

Mrs O'Donnell: Speaking from the perspective of the Ontario Public Health Association, I do not know how to describe it in detail, but we feel the health care system has to be recreated. We have spent 30 years since the inception of medicare persuading people to use a system that is medically modelled. I believe we have to turn that around. We have to reduce the dependence of people on the medical model to increase their sense of personal responsibility for health. We need to do as much as we possibly can in the community, sometimes because it is more cost-effective. Sometimes it may cost the same, but the quality of life is a whole lot better when people can be outside an institution rather than inside an institution, and I think, most important of all, we have to redistribute the resources in a way that will address the determinants of health. I guess it is the old analogy, to prevent people getting pushed into the river upstream so that we can stop pulling them out of the river downstream, which is very costly.

Mr J. Wilson: I would like to ask a question about medicare universality. I will try to make my question succinct, but there are a number of user fees, for instance, in the system now. Every day you read about people worrying about user fees one way or the other. We have some hospitals, some 20% of whose income comes through various forms of user fee, and despite what the government says in the long-term care reform documents, we talk about user fees to some extent for some services.

Do you see a greater role for user fees? I notice one of the briefs talked about waste although it did not exactly say this: My belief is that you are entitled to a second opinion, but when you want a third, fourth and fifth opinion, you pay for it. We do not have a lot of time, but can you briefly tell us -- you have probably batted around ideas on user fees and where they are appropriate, the way people, for instance, are paying a flat rate for ambulance services who clearly cannot afford to pay that flat rate for ambulance services. The government will not admit it, but there are user fees in the system now, and I do not think they are appropriately placed or tested. It is a loaded question; sorry about that.


Mrs O'Donnell: On principle we are opposed to user fees, because it has been demonstrated repeatedly in the United States and Alberta that user fees deter the poor, the people on fixed incomes, the elderly. I do not deny that user fees could be established on a selective basis.

Mr J. Wilson: They are already in the system.

Mrs O'Donnell: Yes. The difficulty is that it often costs more to do it selectively than it does to --

Mr J. Wilson: Let me just clarify. I am not talking about the $5 you charge someone to walk through an emergency room, because I figure it costs $6 just to collect the $5; I agree with you there. Should people be entitled, though, if they can afford a particular service, especially now that specialists are leaving with the cap? Maybe the specialists would stay if people could seek that person out in the private sector.

Mrs O'Donnell: That almost inevitably results in two-tier service, because the people who can afford it buy more, and guess where the professionals are going to focus their attention when it comes to a choice between somebody who cannot afford it and somebody who can. So we are opposed to user fees.

The Chair: Are there any other responses to that?

Mr Timbrell: Let me just say you are right, there are certain user fees in the system now. There is a user fee for everyone in an extended-care bed, whether he is in a home for the aged, a nursing home or, after 60 days, in a chronic-care facility. There are the fees for ambulances and various other ones. We hear the government is thinking of $1 or $2 per prescription under the Ontario drug benefit plan.

Mr J. Wilson: Even parking in the hospital is a user fee. It is over five bucks to get in.

Mr Timbrell: Do not forget that the parking facilities in hospitals are not paid for by the government. Hospitals do not get a dime from the government to build or maintain any parking facilities, so whatever fees you pay are there to support.

It is worth reminding ourselves that there were some myths built up about the funding of medicare 25 years ago that persist to this day. For example, people used to talk, when I was in another role, about 50% of medicare being paid for by the government. The federal government never, ever paid 50% of the cost of medicare. The government of Canada paid for 50% of certain defined services within medicare. They never paid for nursing homes, they never paid for ambulances, they never paid for public health, they never paid for the drug benefit program, they never paid for assistive devices and on and on. In fact, by the time the government of Canada in 1977 got around to passing the established programs financing act, federal government funding was already down to about 42% of total spending. With the enactment of EPF and the change from what was first announced in early 1977 to what was enacted in late 1977, the decline in federal government spending on health care has been going on for 15 years or more.

As I said in our brief, the reality is that the government cannot afford to pay for what we popularly or generally think medicare was or is. What medicare was is gone, and I agree with Mrs O'Donnell that we are talking essentially about rebuilding medicare.

Mrs Edwards: I would like to simply, hopefully, answer Mr Wilson's question. The RNAO believes, in conjunction with OPHA, in accessibility for all individuals for the appropriate level of health care and the appropriate resources they need. There may be activities above and beyond that which individuals, in their wisdom, could elect to have, but we are absolutely adamant that all individuals within the province have the option and the ability to receive the appropriate level of health care they require, be that in the institution or in the community.

Mr MacFarlane: Just a brief comment about user fees. As you know, in the chronic care hospitals there is the co-payment aspect, which is a user fee. As Mr Timbrell said, the same patients are occupying acute-care beds, and acute-care hospitals are not allowed to charge the co-payment. So the charges are related to the type of facility rather than the type of patient, and that seems inconsistent.

Mr Christopherson: I would like to thank the presenters for coming forward today and assisting us in the budget formulation for 1992. I would also like to say, quite to the contrary of what Mr Wilson has suggested, that not only is this not a divisive process, I think it is actually a process of trying to find the kind of common ground we need if we are going to find our way out of the difficulties we have. I am acknowledging it in the context of the responsibility of the opposition parties to do the job they are there to do, but I think it is easy for any of us to be finding differences, focusing on those and making the gaps even bigger.

Mr J. Wilson: That is crazy. That is not what we are doing. That is exactly what you are doing.

Mr Christopherson: Madam Chair, would you please ask Mr Wilson to refrain.

The Chair: I am sorry, I was involved in something else.

Mr Christopherson: I think it is important and incumbent upon all of us who have a responsibility to come together to try to find that common ground as much as possible. We owe a debt of thanks to you people who are prepared to take a chance, to come forward with a new system, a new way of trying to do things, sit at the end of the table like this and dialogue with us. I want to thank you for that. I hope it is the first step of an awfully long path that takes us to the goal we are all seeking.

I would like to ask a question that is indirectly related to the development of the budget but has a lot to do with accountability, responsibility and the whole issue of devolution of decision-making to the community level in terms of health care. It is a simple question. There is some talk now about the possibility of having hospital boards and district health councils elected as opposed to the appointment process, where members would literally run for office as they would for a school board. I would be most interested in the thoughts from the different perspectives represented today on whether you think that would be a benefit, no change or a wrong step.

Mr J. Wilson: What has that got to do with money? You are supposed to keep him on track.

The Chair: The direction of the question may well come out in the end result.


The Chair: Mr Wilson, you were provided the time to ask your questions. Is there anyone here who would wish to answer that?

Mrs O'Donnell: I cannot respond from OPHA because it is not something I have heard discussed at OPHA by OPHA members, although I am certain it has been a topic among a lot of them in their home settings. If boards of health and/or district health councils were to be elected, then obviously the intent would be for them to be accountable for public funds. One would presume that along with the responsibility for the disposition of those funds would come the authority for managing those funds.

From a personal point of view, having been on a health council for six years, I think that would put the responsibility and the authority very close to the public pressures that would fall upon the people in the local setting. That is not altogether a bad thing, but it could make it a very difficult thing. They do not have the distance that has in the past belonged to the government. Queen's Park is far enough away that one can say all sorts of nasty things to Queen's Park and get away with it. I think it would require a lot of time, thought and very careful development if that was the route selected.

Mrs Edwards: I do not have a comment from RNAO's perspective.

Mr MacFarlane: I think what you are looking for is people with the right skills for hospital boards. Most hospitals clearly define the kinds of individuals they need to represent their community, with a mix of the multicultural community, the business community and so on. It is very difficult in an election process to get the kind of mix you need.

Mr Timbrell: It is hard to imagine how introducing partisanship into the provision of hospital services or health services is going to be seen as an improvement. One would also want to remind oneself that school boards started off being appointed bodies of municipal councils. Then they got their independence and were elected and then they got the right to tax. Unless it is part of the government's long-range plan to have locally elected hospital boards granted the right to tax, which is an inevitable evolution of free and democratic elections, then I suspect it is not an idea that is likely to go very far.


Mr Phillips: To get to the heart of the matter, there is no doubt that we are in a financial crisis in health care. There is no doubt also that it is the hospitals that are going to bear the brunt of the problem over the next year or so. The doctors have a six-year deal and they will not appear here for six years. They are in a stormproof shelter, fully sheltered from this stuff. I agree with the comments you made that community-based care is extremely important. You cannot close the hospitals until you have that. That has to be put in place, and I agree totally.

The challenge we face is for the next 12 months. We are talking the next 12 months really, right now, today. As I say, you are going to be the scapegoats. Every government looks for somebody else to blame. It is just the natural way things are. I see it happening right now. There is a public debate about who is to blame for the health crisis and the finger is starting to point at you guys just because that is convenient. The doctors are out of the way and you are next in line.

By the way, I do not think there are heroes and villains in this piece. I really do not think there are good and bad people in this thing and I do not think there are people who are evil and good. Everybody is trying to act in the best interests of the people of Ontario, and that is how I approach this.

My question is primarily to the hospitals. The provincial government is going to say it is the hospitals' fault and the hospitals may very well say it is the provincial government's fault. Can you be helpful to our committee in saying how we minimize that finger-pointing and maximize the truth in this exercise? How can we get some handle on what is the true number needed? I know you have your figure of 8%. How can we evaluate that? Is one way of doing it that whenever a hospital is going to change its program, the hospital and the ministry agree on it? Is that an approach we should be looking at? That may already be part of it.

I am looking just at the next 12 months. I think there is broad agreement by all health professions that the long-term way to go is to get at some of the root causes, more community-based care, all those things. But right now we are focused on the next 12 months, if you do not mind. There is nothing wrong with what you are saying, and we do have to reconfigure it. I wonder if any of you can comment on that? Can the OHA be helpful to us?

Mr Timbrell: The number we have given you is the real number. There has been no gilding of the lily. We purposely did not include in the presentation to the Treasurer anything for the Ontario Public Service Employees Union, the Canadian Union of Public Employees or the Service Employees' International Union, the unions with which we have yet to reach settlements. When you take the government's own mandated programs like pay equity and the pending regulations in occupational health and safety, and you add to that what we know is the impact of the settlement with the operating engineers and the nurses and you add to that the government's own funding formulae for life support, transitional funding, etc, it comes to 8.6%. It is not 8.7%, it is not 8.5%, it is 8.6%.

We also understand what the Treasurer is saying. He does not have the money to pay 8.6% or 9.6% or 10.6%, or whatever it ultimately turns out to be once we have the other settlements.

Should every hospital deal with the ministry? Obviously that is the case, and we are prepared to do that. That does not let anybody off the hook at the ministry or anywhere else from making some very tough decisions. More hospitals will end up with revised mission statements that cut out certain services, like Toronto Hospital. Some services provided in just about every hospital in the province of Ontario today will not be provided in those hospitals six months from now, if not sooner.

Mr Phillips: That is my point. You are going to be hung out to dry, I think, hospital by hospital by hospital.

Mr Timbrell: That remains to be seen, I suppose. Clearly, what we have tried to do is to put forward in a very rational, non-hysterical manner the real facts about what is happening, what is required, and what will happen as a result of getting less than what is required.

We emphasize things like the need for transition. You have heard that from all three of us. I do not know whether it is going to be there. I mean, you get into situations like Blind River, just to choose one example, a little community in northern Ontario that fought for years to get approval to build a new hospital. They finally got approval, conditional upon reducing the number of beds, and they said, "What happens when we reduce the beds?" "Well, don't worry because there will be other programs in the community." The new hospital opens, I think, next month and guess what? The other programs are not there. So there will be a hospital smaller than the one they are giving up, but none of the programs that were supposed to be committed and in place in the community to pick up the slack are going to be there.

Will we be hung out to dry? I do not think so. I think that the public of Ontario very strongly support their community hospitals. That is evidenced by the 40,000 men and women who regularly give their time as volunteers, and the 4,000 men and women who come from every background -- trade union, business, professional, industrial, retired -- and from every segment of the community, to work as voluntary trustees and governors of the hospitals.

We will certainly do our best to keep reminding people of what the hospitals are and how much they have changed, that they are not stuck in the past, and are very much part of the leading edge in health care. But we will also tell what the facts are, what the implications are of the inability of the government to fund what is required.

Ms Danaher: I think it has been acknowledged that in this province there is enough money spent on health care. Ontario spends more on health care, I think, than probably most jurisdictions. So we really have to make a tough decision to reallocate resources. I do not think we need more money. We have to use the money that we have more efficiently, and we alluded in our brief to where some of those cuts could be. We mentioned some of the hospital cuts and also the drug benefit programs where some of those cuts could come. It is taking the first step to say that money from this pile needs to go to a different use. I know they are difficult decisions. But I do not think we need more money in health.

Mrs Edwards: I would like to comment on Mr Phillips' statement of hospital by hospital, because I think therein lies one area where we do need to continue to look closely, that is, the comments that have been made by a number of us today with relation to duplication of services and duplication of care.

We in the Metropolitan Toronto area, perhaps, have a different view of things than in smaller outlying communities. But I think that looking individually hospital by hospital and health agency by health agency at times obscures the global picture for provision of care within that entire environment. Certainly, individual agency by individual agency, there are reasons and rationales to continue to function in the direction we have been functioning. Global environment by global environment would perhaps allow investigation of potential areas of duplication, both in terms of services provided and the level of care giver providing it.

The Chair: Have you a second question, Mr. Phillips?

Mr Phillips: In fairness, I do just keep going around. I do have, but I do not --

The Chair: Okay, Mr Wiseman.

Mr J. Wilson: I thought we were going in rotation.

The Chair: We have been moving back and forth because some people have not indicated they wanted to ask another question. You have had two.

Mr J. Wilson: When Mr Sutherland took the Chair he indicated we would go in rotation, and I should have more questions because I alone am representing my party. This happens on every committee.

The Chair: Mr Wilson, we will get to you. We are going to do this as efficiently and as quickly and as concisely as possible. Thank you very much.


Mr Wiseman: I have a question about what has become a major issue in my riding as of this week: a paediatrician who has just decided he is going to move to the United States. In the US he will get $1,500 per delivery of baby.

Interjection: A paediatrician?

Mr Wiseman: An obstetrician, sorry. In Ontario he gets $242. He can make $1.5 million down there, and he cannot here. I would really like some comments. Now, obviously, our health care system does not have the kind of money in it where we can increase from $242 per delivery to $1,500 per delivery to keep medical practitioners here.

Then I have a second question about how you implement some of the recommendations in the brief from the Ontario Public Health Association.

Mrs Edwards: I would like to comment. In terms of the recent legislative changes that have been made with respect to midwifery, delivery in healthy, full-term pregnancies in which there are no anticipated complications does not necessarily need the services of a physician at a cost of $1,500. The government has been moving, or RNAO feels the government has been moving, in a very supportive manner to provide health care access for Ontarians by individuals who will be well-prepared to provide it. The area of midwifery versus the cost of an obstetrician is a very good example.

Mr Wiseman: With respect, that does not answer the question about the need for an obstetrician to be there at difficult births, or how our system is going to be able to maintain the level of specialists in all areas against the competition and attractive forces south of the border. I do not know if you have an answer to that.

Mr MacFarlane: I would have to share the view that there are alternative professionals who are capable and who should be given opportunities. I know hospitals are quite prepared to train midwives, for example, and other professionals can help. Social workers can assist greatly, if they are properly trained, in work that psychiatrists could assign to them.

Mr Elson: The analogy that comes to mind for me is cross-border shopping. I think people who choose to live in the United States are giving up much more than they may gain in salary. If they are that dissatisfied with the quality of life in Ontario, then more power to them because, as I said, there is much more to life than salary. I tell people when they go and buy something across the border to ask the cashier what happens when he or she gets into an accident or falls sick, what it costs. What happens when her child is sick and she cannot work? Those are the things in the global context that people have to realize when they live in Ontario.

Ms Danaher: I would also support what my other two colleagues have said. You really need the most appropriate person providing care. Do we want to be providing salaries to physicians in the hundreds of thousands of dollars? Do we want to move to an American-style system? There you have 40 million people with no health insurance and another 50 million who are inadequately covered. Those are the consequences when physicians are paid those kinds of salaries and where other people who can provide appropriate caring service are not doing it.

Mr Timbrell: I have not heard anybody proposing an American-style system for Ontarians. I do not know where that came from.

Mrs Sullivan: The deputy minister.

Mr Timbrell: The deputy minister? It would be interesting, number one, to see if that obstetrician does go. It would be interesting to see him when he comes back to Canada after he lives with the cost of malpractice insurance, after he lives with the lifestyle in American cities, after he lives with having to answer the inquiries from literally dozens of third-party insurers and fill out inconsistent forms and have his medical judgement questioned on a daily basis by bureaucrats, not of government, but of the private sector. You may want to start a pool in your riding to guess the date when he will come back.

But it does raise another issue, the whole question of the distribution of medical personnel in the province. Ontario has enough doctors, Ontario has had enough doctors for years. What Ontario does not have, what for that matter no province has, is a system that encourages the proper distribution of physicians. I am not just speaking of northern Ontario, because all your colleagues from the northern ridings will tell you that for years, from Thunder Bay to Winnipeg, there was one pathologist to serve all of that part of Ontario. That doctor was criticized at one time because his billings were in excess, 12 years ago, of $1 million a year. But we could not find anybody else at the time who was willing to be an itinerant pathologist, to go from hospital to hospital from Dryden to Kenora to Fort Frances back to Thunder Bay and so forth -- or psychiatrists.

That is in the north, but there are also serious shortages in the south. I dare say if you go into parts of Oxford county, if you go into parts of Frontenac county, if you go into parts of counties very much closer to Toronto, there are shortages of certain specialties. Nobody has any easy answer to that because there are no easy answers to that. British Columbia tried to limit billing numbers. British Columbia tried any number of things and they were all struck down by the courts. That is a major planning issue that we all have to be concerned about and try to find some better ways to address.

Mr Wiseman: On page 3 of the brief of the Ontario Public Health Association, it says, "Quality of treatment by medication can be improved by improving prescription practices, physicians' knowledge of pharmaceuticals and the recognition and use of the pharmacist as part of a multi-disciplinary decision-making team." Prior to that you suggested perhaps the province should become a little heavy-handed and arbitrary about rolling back costs as well. On page 5 you talk about an epidemic: tobacco and alcohol, preventable accidents, caesarian sections, test drugs and everything.

How do you put into place a system that monitors this or makes sure that, on the one hand, patients are not taking 25 different drugs that are doing counterproductive things in the body, and that they are not getting treatments that are not necessary? How do you do that?

Mr Elson: The introduction of health care, as it becomes more widely used on an individual basis, and the introduction of the smart card will certainly provide a tracking mechanism that was not available before. A lot of the information about drugs and doubling of prescriptions and so forth is information that can be used or is available but has not been used from a system management point of view. It has basically been used as a way to pay for it but not to manage the system.

I have talked to individuals within the user services branch of the Ministry of Health who have been talking about the fact that there is substantive computerized information that could be made available for a different use from a system management point of view. I think there are probably some keys in that area.

Mr J. Wilson: With the minister talking about some $5 billion that could possibly be saved in the system and is currently being wasted, how lean do each of you feel the system really can get before we have a crisis on our hands, given that I have been told by the minister today that there is no crisis now?

Mrs O'Donnell: I do not think the present system, the way we deliver health care at the present time, can be pared back much more without a crisis. Everyone in the system, be it institutional care or public health, agrees that the current system cannot sustain itself much longer. That is not just in Ontario; that is a direct quote from the provincial commission in Alberta as recently as 1990. This system is on the rocks. We have got to change it. How do we go about it? I am having difficulty imagining how we could sit here at the end of the table and come up with an immediate response to that, but it can be done.

Mr J. Wilson: Do not worry. I am going to give you a solution.


Mrs O'Donnell: Are you really? I cannot wait. The system as it stands at the moment has been pared back about as lean as it can go, in my view.

Mr Timbrell: The term "crisis" is one the minister used in her speech to the Ontario Hospital Association convention about two weeks ago at which time she said, "This may be the crisis which everyone has been predicting for years and years." When we choose not to use the term "crisis" or not to do what I call a Henny-Penny, that is not to say there are not concerns, because clearly there are and I think we have been highlighting those from one end of the province to the other.

We recognize that coming out of this difficult period is going to require the best efforts and the best will of the government and ourselves and every other player in it. We have tried to highlight, though, two things.

One is the need for clearly defined objectives, so we know, the public knows, everybody knows what we are working towards and the time frame that is expected.

Two is that there are some very difficult choices which have to be made in the clinical area. While the government did establish a long-term agreement with the medical association, and while there may in fact be some who feel that the members of that profession are somehow not part of the solution, indeed the physicians and every single hospital in the province are engaged in discussions about the implications of the inability of the government to fund the system and what they will have to do -- not what they could do, not what they might do, but what will they have to do -- to help us manage our way through these difficult times, because without that co-operation it simply cannot be done.

Mrs Edward: I would like to echo the words of my colleague at the OHA abput the difficult clinical decisions that will have to be made in terms of the resources required to provide the care that is needed and to make sure everyone has access to that care. Certainly there are duplications and there are times when one test is good so two tests must be better, and the most expensive test is obviously the optimal so we will order all three just to be sure. There are certainly some areas where we can be looking to provide more concrete direction on an individual-by-individual basis in terms of how we can refine our resources.

We also concur with the Ontario Public Health Association comment that the placement of resources needs to be continued given the present form of financing that we have. That is to say, we cannot make major changes to the location of care of patients without providing resources either to place them more long-term in the community or to provide different levels of care providers in institutions.

Mr J. Wilson: It seems to me that what you might want to be lobbying for, as all health care providers and players in the system, is to win over public support, and I am interested to find out from each of you whether this would be at all possible. I have been going around the province saying in my speeches, "I think the government is going to have to stop paving roads for a year or it is going to have to..." and I list a number of things people count on being done every year.

Mrs Sullivan: Except in my riding.

Mr J. Wilson: Except in my riding too. But the Treasurer, to his credit, I noticed on a program the other day, made it very clear that although it has been a long-term policy of the government and of other parties to move towards community-based care -- and I think Mr Phillips hit the nail right on the head. I do not think we can continue the way we are going, in putting an absolute crunch on the institutional care we have and yet not building up the community care.

The government should be honest with the people of Ontario and say, "If you really want to move this way it's going to take a tremendous amount of cash and you are going to have to be willing to give up other programs for a while." That is the recommendation that should come forward from health groups.

Mr Sutherland: So, you are saying spend and save?

Mr J. Wilson: No. Identify the spending, but I will not get into this political debate.

The Chair: Mr MacFarlane.

Mr MacFarlane: I think that is the point. The system is in transition, as we have heard today. There needs to be accommodation from a program point of view to allow that transition to go into place. There needs to be allowance for the transition to occur from a physical plant point of view. Hospitals were not built to provide some of the outpatient ambulatory focus that they are now required and determined to do. There has to be funding to bridge between a current system and structure programmatically and physical plant-wise to allow it to change properly and to direct the change with the standards which are required.

One of the areas where hospitals could generate revenue, for example, would be if they were allowed to build for laboratory outpatient work in the same way private labs do. This would allow income to hospitals to offset some of these escalating cost problems, but they are not allowed to do that.

The Chair: I am going to move questioning now to Mrs Sullivan and then to Ms Ward, and then I am going to cut off questions because there are two other very brief agenda items that we must deal with.

Mrs Sullivan: Thank you. I want to move into another area related to fiscal and financial demand. We have just started, actually, to move into that area. Before I do, I wanted to have a confirmation from the Ontario Hospital Association that this steering committee program review report is due tomorrow. Is that going to be coming forward?

Mr Timbrell: I believe it is going to cabinet or the Treasury. I do not believe it is going to be released publicly. But it is also not very definitive. It is a set of options. It is not making any definitive recommendations.

Mrs Sullivan: Okay. The next area relates to capital. There had been a commitment in the 1990 budget of close to $1.33 billion worth of capital over a four-year period. Some $500 million of that has been committed so far. Another small amount of capital is being deferred to next year. To conclude that capital commitment, the next budget should be committing for the next two years something in the nature of $900 million in capital, including the deferred capital for this year. Presumably, there ought to be a commitment of, indeed, the next phase of a multi-year capital program. What are you placing before the Treasurer in terms of capital requirements relating to a multi-year program or asking the government to honour the commitment relating to past capital announcements that have been made?

Mr Timbrell: We have been pursuing the 1990 set of commitments, a number of which have been delayed, as you have indicated. I have to tell you the indications we have had so far are that they will not be honoured, that there will likely be a new capital plan announced. We have been told to expect that a number of communities will be told, after waiting for years and years for replacement hospitals or new wings or whatever, that their projects simply are not going to proceed at all. We have not yet got into the criteria, although, in fact, it is on the agenda for our meeting with the ministry next Friday under the new joint planning process; but clearly they have got to relate to what is happening across the province in discussions of downsizing. That may very well lead, as it is leading already in Windsor and perhaps in some other communities, to discussions of abandoning whole hospitals and merging or simply closing hospitals and seeing the programs and activities dispersed over other facilities in the area.

Mrs Sullivan: One of the things which is also a part of capital, that is, not only building, relates to equipment that is required in hospitals. I noticed what I thought was a very peculiar change in policy relating to CAT scanners where hospitals are now having to go back and reapply and where the commitment is very different. There is not going to be ongoing operating funding. There is going to be one-time funding. Particularly in our teaching and tertiary care hospitals, but not necessarily limited to those, the emphasis on capital spending for high-tech equipment, even with a move to community-based care, is still going to be a vital aspect of that. Has there been any indication of the nature of capital commitment in terms of emerging technologies and new equipment or of increased commitment to provide assistance in research and development, in which Ontario is also falling behind many other provinces?


Mr MacFarlane: You may be aware that hospitals are required to provide their own capital for equipment replacement and for new equipment outside of that portion of equipment which is part of a new hospital, for example. There are tremendous pressures on hospitals to fund-raise in their local communities to purchase new technology, to keep up to date and to replace equipment which is outdated, often at a multiple of the cost of the old piece of equipment, because of changes. There is a major need for capital, just for equipment replacement in hospitals, that does not get government assistance.

Mr Timbrell: To further answer your question as to whether there is any indication that they are prepared to fund new technology beyond what we have now, no. Is there any indication that they are prepared to fund enhanced R and D in either the development or use of new technology? No.

Mrs Sullivan: If I could pursue with the RNAO the question of human resources planning, one of the things that is clear to me, particularly after the Regulated Health Professions Act changes, is that the emphasis on the RNs in home care is going to have to increase because of the nature of the scope of practice. The training and delivery of RN services is going to have to be put into a very different focus outside the hospital than it is now. I do not know if the hospitals want to talk about this as well, but what is the impact in terms of human resources planning of a move to community-based care when it is going to be the RNs, because of the scope of practice, who have to deliver specific kinds of services?

Mrs Edwards: One issue on which the RNAO has joined with other provincial nursing professional associations, and the Canadian Nurses Association as well, over the past 15 years is something called "entry to practice," which means that by the year 2000 the goal is that the basic entry level -- ie, basic educational preparation -- for a beginning nurse will be a baccalaureate degree. What you are, I think, alluding to is the fact that in the community the autonomous practice, the independent decision-making, very much functioning as an autonomous professional not under the specific and daily direction of another health care profession, is going to increase as the needs and complexity and type of patient in the community change. Certainly the RNAO has been supportive of the transfer and development of educational programs in addition to, and eventually alteration from, diploma programs that are currently provided.

The reality in Ontario is that we are probably the farthest behind any Canadian province in this area, because of the major complexity. We have 22 community colleges and nine universities that have nursing programs. The majority of other provinces have at most one, maybe two universities and a couple of either hospital-based or community college programs. We recognize, when we face the wall, that in reality we will not make that goal by the year 2000. But the focus on adequate preparation in order to ensure that the clients in the community have somebody who is able to use the assessment skills and intervention required to keep them in the community, is going to require a different form of educational preparation. I would be interested to hear what my colleague in the community would have to say to that.

Mrs O'Donnell: The home care programs have till now been primarily housed with health units, so we are quite familiar with the demands of the nurses who work in home care providing treatment and care. One of the reasons I am not alarmed at the thought of having the home care organizations move out of health units is that the health unit focus is promotion and prevention, whereas home care is a treatment and care facility. The nurses in those settings will require the higher level of preparation.

There are some really interesting initiatives under way at the present time between RNAO, Ryerson and some of the community colleges as well to institute some kind of laddering system whereby a variety of levels of care giver will be able to work through the system. It is anticipated that working in the community will require the top level of preparation, because of the judgements that have to be made independently, without immediate supervision.

Mr Timbrell: I have two quick points. Clearly one of the human resources management issues that every hospital CEO and his staff deal with every day is the the allocation and the utilization of the appropriately trained staff. Whether it is RNAs, RNs or baccalaureates, there is a role for all of them in various types of daily tasks within the hospitals, and within the communities. Apropos Mrs O'Donnell's comment about health units and their role and perhaps seeing home care move away, I have to say that if the health units are no longer prepared to do it or think it is not appropriate, we think it quite appropriate that the hospitals in many communities in this province get involved in overseeing the operation of the home care programs to properly co-ordinate admission and discharge, to keep people out of hospitals who do not need to be there, to get people home sooner who do not need to be in hospital, to avoid the duplication and the cost of administration and to ensure consistency in the approach in those communities.

Ms M. Ward: I think it is a good idea to have representatives from different parts of the health care system here together. Actually, I was surprised myself to see the co-operation that is out there. Last week I was at an annual meeting at Flemingdon Health Centre. They are working in conjunction with two different hospitals and with East York health unit in different programs. My question may be a little parochial. It has to do with my area, Metropolitan Toronto, and is about health units.

I do not know what part of the province you are from, but Mr Timbrell would likely be familiar with this issue -- the different level of funding for the Metro Toronto health units and the rest of the province. I think it is 40% in the Toronto area and 75% elsewhere. There are historical reasons for it. Do you think the health units in the Metropolitan Toronto area are too small and should be amalgamated -- I guess that was one of the reasons they did not get the same level of funding in the first place -- or should they stay the way they are and the funding level be increased?

You have two recommendations here in your paper about the health units, asking for $60 million in funding for their mandatory core programs, which became required in 1989. Then you have another recommendation about the division of funding. I wonder if you could comment on that.

Mrs O'Donnell: My mind is bouncing around a number of aspects of your question. In the first place, speaking generically about public health, the prevention/promotion part of the health care system, at present it consumes somewhere between 2% and 4% of the health budget in Ontario. So when we look towards a percentage increase in public health, it represents a relatively small drop in the bucket but a major component for the people delivering the care.

There is a very complex history to the Metro funding as compared with the rest of the province. To oversimplify, when public health first began in Ontario, Toronto was one of the first to get into the system. The Toronto municipality had started developing its programming. They had a huge tax base on which to collect the taxes that they used, without provincial help, to provide public health at that time.


When the more rural communities were -- I will not say uninterested -- disinclined to contribute to public health, provincial funding was begun to encourage this particular aspect of health care. I believe that over time the per capita expenditure in public health in Toronto exceeded the per capita in other parts of the province.

Ms M. Ward: Can I interrupt? You are speaking of the city of Toronto, not the other municipalities?

Mrs O'Donnell: You have me on that one. I am sorry, I do not know enough to respond.

Ms M. Ward: There is a fair difference. In East York, which I am familiar with, and probably in the city of York the per capita level of spending is much lower, because they do not have the base. I am sorry, I should not have interrupted you.

Mrs O'Donnell: No, that is quite all right.

Mr Elson: Certainly it is one of the main reasons we are advocating for the disentanglement issue to be resolved, because it is not unlike the situations that hospitals face. We have provincially mandated core programs that municipalities cannot afford to purchase. In many cases at a regional level it is literally a purchase agreement.

Historically, the budgetary allowance for public health has not been taken up, because whether it is a rural community in the north or one in Metropolitan Toronto, the money only comes from the province when there is the proportional allotment from the municipalities. Right across the province that money is not there, so they are faced with a dilemma: Do we not deliver the mandatory core programs? If so, then what level of service is a community prepared to accept?

It is really tough, particularly when there are some programs that are 100% funded where they are not tied dollars. But where they are tied dollars, then it becomes a real dilemma, because the municipalities, particularly this year, have already voted 0% increases. So whether the money exists within the provincial government or not, they cannot even access it. It is a real problem for us.

Ms M. Ward: You would not comment then on whether those units are not too small or --

Mrs O'Donnell: Underfunded.

Ms M. Ward: Yes, underfunded.

Mrs O'Donnell: I do not feel I could comment on that, but I do feel that the issue Peter has spoken to is a critical one. When there are two different sources of funding, both must be in place. If the municipality says its share is not forthcoming, then the provincial money does not come. Similarly, if the local community wants something as a priority that does not fit with provincial priorities, the province can withhold. In either case, no funds come to the agency to provide the service.

Ms M. Ward: Ideally, all those mandatory programs should be provincially funded.

Mrs O'Donnell: This is certainly the position of a lot of people in public health.

The Chair: Thanks to all of you for coming this afternoon to present to us and for being so responsible and responsive in staying so long to answer our questions.

A point of order has been raised.

Mrs Sullivan: As we have indicated, this is a new and bizarre process of pre-budget hearings. Today we have had people who are involved in carrying out the services represented by over a third of the provincial budget. It seems significant to me that the Ontario Medical Association --

Interjection: Declined it.

Mrs Sullivan: I know -- has declined the invitation, when indeed we have heard that the utilization questions and the settlement question in terms of the OMA settlement with the government have significantly affected many of the decisions that surround the budget preparation process and the nature of the hearings. Frankly, while the OHA and the RNAO and the public health association were very responsive and put a lot of time into their briefs, there is a significant gap in what is available to this committee and to others in terms of a real discussion of the health care portion of the budget. I want to put that on record. I think it is disturbing and surprising that the Ontario Medical Association declined the invitation to appear.

The Chair: A point well taken and it will be recorded. There are two items not on the agenda, and we have a very short time to deal with them. One of them is that we have received a request from the Treasurer that he himself wishes to appear before this committee. I know that is separate from the Treasury staff who will be coming on the afternoon of the 5th. I am wanting to refer this to the subcommittee for a discussion, because the time is short here, or should we --

Mrs Sullivan: Oh, sure, bring him in.

The Chair: You want him instead of the Treasury staff, along with the Treasury staff --

Mr Sutherland: I believe he is coming to talk about process, how we can open up the budgetary process overall, more than the exact figures, which is what the Treasury staff is coming for.

Mr Phillips: When is Ron coming? We have Ruth here, but where is our ex-Chairman's painting?

The Chair: We can have him paint his picture on the wall.

Mr Sutherland: I think we should have the Treasurer come because we do not have anything scheduled for the 12th or the 19th so we could easily accommodate the Treasurer to talk about opening up the process.

The Chair: Is there a specific date? Either of those dates?

Mr Christopherson: My understanding from my discussions with the Treasurer is that he would like to come as soon as he can to give us ample time to do our planning, and I would suggest that from his presentation may flow some of the discussions we will have around what we are going to be doing in the winter and how we will be conducting the pre-budget consultation. If you wish, I would be quite prepared to work with the clerk and the Treasurer's office to have Floyd come in as soon as possible to give us as much latitude as possible, and keep that separate from the presentation of the Treasury people on the facts and figures of the economy, so that there is ample time for both discussions.

The Chair: Is that agreed? There is no problem with that? Fine.

Mr Phillips: Will you tell him about Ron?

The Chair: I thought you were going to do the painting.

Mr Sutherland: He has been told.

The Chair: There is one other matter. It has been suggested to me that it be referred to the subcommittee, but we are to schedule the next sitting times and the focus of those sitting times so that they may be put on the agenda.

Mr Christopherson: Could I suggest that the committee today authorize co-ordination between the clerk, myself as the PA and the Treasurer and then the Treasurer's staff, in setting the agenda for the next couple of meetings? That would maybe save us a step now.

Mr Phillips: What are we dealing with?

Mr Christopherson: We are talking about the Treasurer's letter wherein he would like to come forward and talk about the nature of the pre-budget consultations for the new year, and also your request to have Treasury staff come forward. I am just saying that if the committee today would empower the Chair and the clerk, I will be willing to work with them to bring those two entities here as quickly as possible, and they have the authority to go ahead and just schedule, rather than going through the subcommittee. But if you feel that is --

Mr Phillips: We set aside the 5th for it, did we not, the afternoon?

The Chair: We set aside the 5th for the Treasury staff.

Mr Phillips: That is fine with me.

Mr Christopherson: I do not know personally if that has been confirmed or not. That is all I am saying.

Interjection: The whole day?

Mr Phillips: Just the afternoon, I think, for the staff.

The Chair: This is a separate item. Since that has been agreed upon, what the whip's office wishes to know is how many weeks of sitting time this committee would like to request for the winter session, and that might appropriately be dealt with by the subcommittee.

Mr Christopherson: Do you want to have them do it after the Treasurer comes in and we have had that discussion, and get the subcommittee to crunch on things and come back with a recommendation?

Mr Phillips: I know Monte will be in the country some time soon.

Mr Sutherland: Where is he? We have not seen him for -- what? -- about a month.

The Chair: Shall I take it then that we will refer that to the subcommittee and that there should --

Interjection: Are you sure he is not out campaigning for committee Chair?

Mr Phillips: Madam Chair, I am assuming next Thursday afternoon is the Treasury people and then you set up the meeting with the Treasurer, and that is on an ASAP basis. Then the subcommittee, I think, should try to meet some time in the next couple of weeks to map out --

The Chair: Decide on the winter session.

Mr Phillips: In my opinion, yes.

Mr Christopherson: That is fine. I was just acknowledging that I cannot say with any certainty that next Thursday afternoon is Treasury staff. It looks like it is, but I do not know that for sure. I think we need to firm that up.

The Chair: Has that not been confirmed yet?

Mr Christopherson: I am not aware of the confirmation. That is all I am saying. I do not want to make a commitment to Gerry and then find out it is not there and he says, "Dave, you didn't say anything last week that it was a problem." I am just acknowledging I do not have that --

Mr Sutherland: That is right. It will be all your fault, Dave.

Mr Christopherson: If there is a problem, though, we will just blame Kimble and straighten it out afterwards.

The committee adjourned at 1801.