Wednesday 14 August 1991

Regulated Health Professions Act, 1991, and companion legislation / Loi de 1991 sur les professions de la santé réglementées et les projets de loi qui l'accompagnent

Ontario Physiotherapy Association

Interim Regulatory Council on Midwifery / Conseil intérimaire sur la réglementation de la profession de sage-femme

Toronto Birth Centre

Registered Nurses' Association of Ontario

Board of Directors of Masseurs of Ontario

Ontario Chiropractic Association

Ontario Hospital Association

REAL Women of Canada

Steven Goring

Jane Chamberlin

Norma McLaughlin

Board of Directors of Drugless Therapy and Naturopathy

Ontario Naturopathic Association

Jennifer Giavedoni; Jane Dely



Chair: Caplan, Elinor (Oriole L)

Vice-Chair: Cordiano, Joseph (Lawrence L)

Beer, Charles (York North L)

Haeck, Christel (St. Catharines-Brock NDP)

Hope, Randy R. (Chatham-Kent NDP)

Malkowski, Gary (York East NDP)

Martin, Tony (Sault Ste Marie NDP)

McLeod, Lyn (Fort William L)

Owens, Stephen (Scarborough Centre NDP)

Silipo, Tony (Dovercourt NDP)

Wilson, Jim (Simcoe West PC)

Witmer, Elizabeth (Waterloo North PC)


Grandmaître, Bernard (Ottawa East L) for Mrs McLeod

Huget, Bob (Sarnia NDP) for Ms Haeck

Jackson, Cameron (Burlington South PC) for Mrs Witmer

Waters, Daniel (Muskoka-Georgian Bay NDP) for Mr Malkowski

Wessenger, Paul (Simcoe Centre NDP) for Mr Silipo

Clerk: Mellor, Lynn

Staff: Gardner, Bob, Research Officer, Legislative Research Office

The committee met at 1000 in committee room 2.


Resuming consideration of Bill 43, the Regulated Health Professions Act, 1991, and its companion legislation, Bills 44-64.

Reprise de l'étude du projet de loi 43, Loi sur les professions de la santé réglementées et les projets de loi, 44 à 64, qui l'accompagnent.


The Chair: Good morning. I would like to welcome you all here this morning. We are going to begin with a presentation from the Ontario Physiotherapy Association. I ask that you leave a few minutes for questions from committee members following your presentation. You have 20 minutes. Would you begin now.

Ms Brien: Good morning, Madam Chairman, committee members. My name is Heather Brien. I am president of the Ontario Physiotherapy Association. Currently I work as a physiotherapy supervisor in the rehabilitation department of Women's College Hospital here in Toronto. With me are Marel Fielding and Signe Holstein. Marel Fielding is past president of the association and the current chairman of the association's RHPA committee. Marel is manager of physiotherapy services at University Hospital in London, Ontario. Signe Holstein is executive director of the association. Signe has worked as a physical therapist, as an educator and as a manager of physiotherapy services for 23 years. The Ontario Physiotherapy Association represents the majority of practising physiotherapists in Ontario and is part of the Canadian Physiotherapy Association.

Physiotherapists, or physical therapists, practise their profession in hospitals, nursing homes, homes for the aged, schools, industries, the community and in private practice. The practice of physiotherapy has evolved over the years in response to the advances in medical knowledge and technology and to the needs of the population of the province. There has been, and continues to be, an increase in demand for physiotherapy services. The greying of the population, the public's involvement in sports-related activities and fitness, and medical advances such as transplantation techniques have all contributed to this demand.

Physiotherapy is a leading health care discipline in rehabilitation services. Physiotherapy is a key to mobility and independent lifestyle. Physiotherapy works in partnership with a patient to achieve the best results, be it relief of pain, moving joints, strengthening muscles, learning to function after major surgery or accident, dealing with chest or heart problems and so on. Should complete relief of pain or return to normal function not be possible, the goal of treatment would involve development of techniques to enable the patient to live with the restriction imposed by the disease, disorder or dysfunction. As well, physiotherapy intervention includes teaching a patient how to prevent recurrence.

Apart from medical doctors and nurses, physiotherapists are unique in that they can intervene throughout a patient's life cycle at any stage of the disease process, from critical to chronic, and in institution, clinic or home settings. For instance, you may come in contact with a physiotherapist in a neonatal intensive-care unit working with premature infants, in a coronary care unit following bypass surgery or in long-term care and palliative care setting.

Physiotherapists are university-educated and -trained and receive their education at one of five universities in Ontario: the University of Toronto, the University of Western Ontario, Queen's University, the University of Ottawa and McMaster University. The programs are usually four-year honours leading to a bachelor of science physical therapy degree. Included in the educational program is a component of a total of seven months of clinical practice.

On behalf of the association's 3,300 members, I would like to express our general pleasure with the proposed legislation. Physiotherapists are pleased by the proposed act's recognition of physiotherapists as primary care givers. We are also pleased by the suggested amendment to Bill 62, the Physiotherapy Act, that adds the controlled act of tracheo-suctioning, a procedure currently performed by physiotherapists that was apparently overlooked in drafting the legislation.

The Ontario Physiotherapy Association has three outstanding concerns that are extremely important to the practice of physiotherapy. All three issues could be resolved without much difficulty. The issues are, first, protection of both our profession's equally valid professional descriptors, "physiotherapist" and "physical therapist"; second, matters dealing with the controlled acts of diagnosis, communication to a patient the cause of his disease, disorder or dysfunction; and third, performing procedures below the dermis.

I will have Marel Fielding address our concerns related to title, Signe Holstein will address our position on the matter of diagnosis and I will conclude with the procedures below the dermis.

Ms Fielding: Members of the public must be able to identify different health care providers. This is the cornerstone of consumer protection in the proposed legislation and in the regulation of the province's health care professionals. It assists patients to make informed choices. The Physiotherapy Act proposes to protect the title "physiotherapist" but not "physical therapist." Since both terms are uniquely associated with the profession, we believe this will be confusing to the public.

One of the fundamental processes of the Health Professions Legislation Review was to protect the consumer from unlicensed, untrained and unethical practitioners who would hold themselves out to be something they are not. In Ontario and indeed in all of Canada, physiotherapists are known equally and interchangeably as physical therapists. Most physiotherapists graduate with a degree in physical therapy. The terms "physiotherapist" and "physical therapist" are protected under our current legislation and are protected titles in seven out of nine other provinces. To us and to most health care providers, the terms are synonymous.

Accordingly, we believe it is essential, in order to protect the consumer, to prevent confusion and be consistent with current practice, that the terms "physical therapist" and "physiotherapist" be protected titles under the new legislation. We believe that Bill 62, the Physiotherapy Act, should be amended to insert "or physical therapist" wherever "physiotherapist" occurs.

Ms Holstein: Equally important to the current and continuing practice of physiotherapy is the issue of communication of a conclusion identifying a disease, disorder or dysfunction. This act, which we refer to in shorthand as the act of diagnosis, has been replaced under the proposed regulated Health Professions Act as a controlled act defined as, in short, "communicating a conclusion identifying a disease, disorder or dysfunction as the cause of circumstances under which the patient can reasonably be expected to rely on the conclusion."

Our code of ethics and rules of conduct state that "a physical therapist...must give the client or surrogate the opportunity to consent or decline treatment" based on "the physiotherapist's objective findings, clinical diagnosis, treatment plan...."

Physical therapy diagnosis is not merely a description of symptoms; it is a conclusion relative to a disorder or dysfunction. We do not diagnose disease entities, nor do we wish to do so. However, physiotherapists regularly communicate the conclusions as a result of evaluation identifying the cause of the disorder or dysfunction. To correct this oversight, the Ontario Physiotherapy Association recommends an amendment to the wording of the Physiotherapy Act that would allow physiotherapists or physical therapists to communicate a conclusion identifying a disorder or dysfunction as the cause of symptoms. This amendment is consistent with physiotherapists' primary care status under the legislation, with our education and with patient expectations.

Ms Brien: Our last concern relates to a controlled act that has not been included for physiotherapists under this new legislation, and again, the omission would have significant impact on the practice of physiotherapy. In question is the controlled act of performing a procedure beyond the dermis. Physiotherapists do not perform surgery, but we do, for instance, perform escharotomy in the management of burn patients. In plain language, we remove dead tissue from burn sites to allow new skin to form and tissue to heal. Physiotherapists also remove sutures and K-wires in some treatment situations. These procedures are an integral part of physiotherapy treatment in specialized settings. To correct this, the Ontario Physiotherapy Association recommends the inclusion in the proposed Physiotherapy Act, having limited controlled acts allowing physiotherapists to perform certain procedures beyond the dermis.

Physiotherapy is a vital part of health care delivery in this province. The demand for physiotherapy is increasing and will continue to increase with the greying of the population. We ask you to help ensure that consumers of physiotherapy services benefit from our training and are able to make informed choices about treatment by attending to our three concerns: (1) protection of our two equally valid titles, "physiotherapist" and "physical therapist"; (2) permission for us to continue to communicate a conclusion identifying a disease or disorder as the cause of symptoms; and (3) inclusion in our scope of practice the controlled act of performing a procedure beyond the dermis. Thank you for your attention. We would now welcome your questions.


Mr Beer: Thank you very much for your presentation and setting out clearly the concerns that you have. With respect to the title "physical therapist," what arguments were you given as to why that should not be protected as well? I think you mentioned in your brief that seven provinces have that.

Ms Fielding: I think it was an attempt, which we agree with to a degree, that the act should be kept as simple and clear as possible. They would really like to protect only one title for each profession. For us that is very difficult because both the terms are used interchangeably all the time. They mean the same thing to us and we think it would be very confusing.

Mr Beer: In terms of the other people who may use that, is that a problem right now? Am I right that it is protected now?

Ms Fielding: Yes, it is protected under the Drugless Practitioners Act.

Mr Beer: If you discover, say, a kinesiologist who is using that title, then you can have that person stopped, is that correct?

Ms Fielding: Yes, our board of directors, the current regulatory body, would send them a cease and desist letter.

Mr Beer: Does that happen very often in the present situation?

Ms Fielding: Not so often, but it is happening. They are suggesting that they are physiotherapists.

Mr Beer: Does that tend to be more from ignorance than wilfully doing that? I am calling for a conclusion, which I should not do.

Ms Fielding: I could not really answer that one.

Mr Beer: Okay, that is fine. Thank you.

Mr J. Wilson: I am just wondering, in not allowing you the authorized act to perform procedures below the dermis, was that an oversight or are you saying it is current practice? Did the review committee consider it and turn it down or is it just an oversight, you figure, on its part?

Ms Holstein: We have discussed that particular issue at some length and have particularly discussed the concept of a limited controlled act. There are some concerns about the level of that limited controlled act and we did not reach any consensus on that.

Mr Hope: Just dealing with some of the comments about jobs you already do, in particular dealing with removal of the stitches, is that not normally performed by the nursing profession more than --

Ms Fielding: It could be. I think it is the kind of situation where the physiotherapist would be working as a member of a team. It could be a nurse, an occupational therapist, a physiotherapist or a physician.

Particularly now, when a lot of patients are being sent home perhaps to a remoter community, the home care people might be sending in several different disciplines. It could be the physiotherapist, and if it is the opportune time to do it the physiotherapist would do it. It just would depend on whichever professional was working with the client that day when it was due to come out, and that professional would do it.

Mr Hope: Would you not need a medical analysis of why something has gone wrong in the surgery itself or why the infection has grown?

Ms Fielding: These are very routine things. Of course the client would be sent back to the physician to review it if there was an infection or something. But these are routine things, not infections and so forth.

Mr Hope: You would not be making a diagnosis of the --

Ms Fielding: We would be coming to a conclusion and perhaps sending it back. We would be making a diagnosis but we would not communicate it. We would send the patient back to the physician.

Mr Jackson: I want to return to your first concern. If the legislation is passed in its present form, that means we would have no legislation governing physical therapists. This legislation exists in seven other provinces, I understand? Is the distinction strong enough between the two? What, in your opinion, would occur for people setting themselves out as a physical therapist without any regulatory guidance?

Ms Fielding: There really is no distinction in our minds between the two. What we could see happening is that perhaps people coming in from the United States who are physical therapists in the United States could, I suppose, practise without being regulated by our college, because the college would only regulate physiotherapists.

Mr Jackson: In Ontario, then, there is not the distinction in your mind, but in other jurisdictions there is a distinction.

Ms Fielding: There is no distinction. I think it is just a different terminology. In the US they use "physical therapist." In various different countries across the world they use "physiotherapist" and "physical therapist" interchangeably. The British term is "physiotherapist," the American term is "physical therapist." It is scattered. The World Confederation for Physical Therapy uses the term "physical therapist." It is too hard to translate. Some of them translate better one way or the other.

Mr Jackson: I think I understand that better. Thank you.

The Chair: Thank you very much for your presentation. We appreciate your coming before this committee this morning.


The Chair: I would like to call next the Interim Regulatory Council on Midwifery and ask that you come forward and begin your presentation by introducing yourselves to the committee. You have 20 minutes for your presentation and we would ask that you leave a few minutes, if you will, for questions from the committee at the end of your presentation. Thank you very much. Please be seated. Your time begins now.

Mme Eberts : Mesdames, messieurs, nous sommes heureuses de venir ce matin vous présenter le mémoire du Conseil intérimaire sur la réglementation de la profession de sage-femme au sujet des projets de loi 43 et 56, qui sont si importants pour l'intégration des sages-femmes dans le système de santé de l'Ontario.

Je m'appelle Mary Eberts ; je suis présidente du conseil. Je ne travaille pas comme sage-femme, mais comme avocate. Ma collègue, Wendy Sutton, est une des représentantes des consommatrices au conseil et fait aussi partie de son comité de direction.

The Interim Regulatory Council on Midwifery was created by order in council under the Ministry of Health Act in May 1989 to act as an advisory committee to the Minister of Health on such matters as the development of standards of practice and the establishment of criteria for certification of midwives in Ontario. The order in council sets December 31, 1991, as the sunset date for the IRCM. We hope that this timing will mesh closely with the proclamation of the Midwifery Act and establishment under that act of a transitional council for the statutory College of Midwives.

There are 13 order-in-council members of the IRCM, drawn from health care and other professions and from consumers. None of the order-in-council members are practising midwives.

Since its outset, the IRCM has had a liaison committee appointed by the Association of Ontario Midwives. It consists of nine people, and the 13 order-in-council members and the nine midwife members of the liaison committee have worked closely over the past two years. We believe that our experience in working together, both midwives and non-midwives, should bestow great confidence on those who think that greater public involvement in professional governments will have negative consequences. The midwives, to whom the initial stages of their profession are so important, have worked very helpfully and very well with us in this unusual arrangement. To them goes great credit, and I believe that the experiment we have been involved in shows the wisdom of the Regulated Health Professions Act in including more consumer and non-professional representation on the governing councils. Although there are consumers among the order-in-council appointees of IRCM, the council has also established a structure to facilitate regular contact between the IRCM and the Midwifery Task Force of Ontario, a major consumer group. Their participation as observers and in regular meetings with us have greatly strengthened our work at the council.


At its inception, the IRCM set up four standing committees. The standards and qualifications committee has developed a number of standards and guidelines, which have been discussed and approved by the council as a whole. These include: a statement of philosophy of midwifery care in Ontario; core competencies; a code of ethics; indications for mandatory consultation and transfer of care; laboratory testing and diagnostic imaging; and a statement on home birth. Toutes ces déclarations de politiques et de philosophie sont disponibles en français et en anglais. Vous les trouverez dans le petit livre de documents qui accompagne notre mémoire.

Le comité sur la législation et sur l'éducation du public a publié deux rédactions de la Gazette et un bulletin bilingue qui est largement distribué dans la province. It has met with the professional associations and governing councils of the other health care professions and established working relations with them, has participated as a member of Interhealth and engaged in various public education activities throughout the province in both English and French, including video programs which are available across the country.

The bylaws committee has drafted a working paper for the operation of the IRCM and is responsible for drafting the bylaw structure for the proposed College of Midwives.

The equity committee is, we believe, something of an innovation in professional governance, and something of which we are very proud. The IRCM and liaison committee wished from the outset to ensure that the profession and its governing body are responsive to different groups who are interested in midwifery as a profession or as a service. The equity committee was created to help us achieve this aim. It has undertaken extensive consultation and visits: in St Jacob's in southwestern Ontario, to learn firsthand how a rural area with a large Mennonite population has developed family-based midwifery care; with native communities in northwestern Ontario, to discuss their traditional practices and explore with them the impact of regulation, and with various groups in eastern Ontario. The committee is currently directing its attention to different cultural groups within the urban core of southern Ontario. These consultations, and the committee's other research, have broadened and enriched the perspective of the council in important ways.

You will also find in the brief of documents our brief to the Public Hospitals Act committee, with respect to which my colleague will have further comments.

In addition to its own committee work, the IRCM has worked closely with the curriculum design committee and the midwifery integration project planning committee set up by the Ministry of Health. We have endorsed the submissions of the CDC to government, a summary of which is in our brief of documents, and the work to date of the MIPP, in connection with which our work on core competencies was done. We look forward to reviewing the final report of the MIPP at our August meeting.

Parenthetically, I might add that among the recommendations of the CDC, which we endorsed, was the proposal that midwives qualify in Ontario by pursuing a baccalaureate program at the university level. We also endorse the recommendation of both the Task Force on the Implementation of Midwifery in Ontario in 1987 and the MIPP that there be a pre-registration program to facilitate the integration of current practical midwives into the profession.

The IRCM meetings are held in public on a regular basis. In our first year, we had 10 meetings. This year, with an increased workload in the committees and the same budget, we had to cut back to eight meetings. A schedule of meetings is published in advance, and upon prior notice, the IRCM will provide French-language translation services to members of the public who request them.

In our use of French, the IRCM reflects its commitment to the spirit as well as the letter of the French Language Services Act. This commitment is an important part of reflecting the diversity of Ontario.

Par conséquent, nous traduisons non seulement les déclarations de politiques et de philosophie ainsi que la Gazette, mais aussi les procès-verbaux des réunions publiques du conseil et des mémoires comme le présent. La vice-présidente et l'une des membres du conseil sont francophones, et la présidente, comme vous pouvez le voir, ne fait que des efforts.

Native midwifery has been an important concern of the IRCM since its inception. The equity committee has given priority to establishing liaison with native groups in northwestern Ontario, and its activities have included consultations in several native communities. We are therefore very pleased that native organizations have stressed the importance to them of having community control of midwifery and input into its governance and have begun to meet with ministry officials on these issues. We support this consultative process and believe it should lead to a great accommodation of the distinct traditional values and practices of the native community.

The Interim Regulatory Council on Midwifery has reviewed both the Midwifery Act and the Regulated Health Professions Act, and we support the legislation and its focus on public protection, public representation and consumer choice. We are pleased too that the protected title in the legislation is "midwife." In our experience, consumers refer to their midwife as a midwife, not as their registered midwife. The generic title will also prevent the unfortunate growth of two professions, one called registered midwife which operates within a statutory framework and one called midwife which operates outside it, a bifurcated profession, which has unfortunately been the result of legislation in several American states.

Successive provincial governments have clearly supported the introduction of legislation after having widely consulted both consumers and health professionals across the province. We believe that Ontario has some catching up to do, as Canada is one of the few World Health Organization countries and one of the few industrialized countries in the world that does not recognize midwifery, but are pleased that Ontario is taking the lead in this. We believe that the integration of midwifery into the Ontario health care system reflects current trends towards community-based care and consumer choice of care giver and reflects the increased desire of women and families to experience pregnancy and birth as normal, healthy physiological processes.

Let me turn to my colleague now for some comments on the amendment.

Ms Sutton: The Interim Regulatory Council on Midwifery supports government motions respecting amendments to the Midwifery Act, specifically section 4, paragraphs 5, 6 and 7, regarding heel pricks on newborns, catheterization and prescribing.

In addition, the IRCM requests that the committee recommend amendments in order to allow midwives the right to start intravenous therapy and perform venipuncture. We understand the provisions in the act respecting emergencies would permit midwives to start intravenous therapy in the event of an emergency. However, in order for midwives to achieve a certain level of skill and maintain this skill level, it will be necessary for them to start intravenous on a regular basis, for example, in in-hospital augmentation of slow labour by means of intravenous.

We recommend that midwives be permitted to perform venipuncture because this addition will enhance the convenience of consumers and their access to continuous midwifery care, particularly in isolated areas. The ability to do venipuncture is particularly useful in the home birth situation for Rh testing and reassurance with regard to haemoglobin levels during post-natal testing. We are aware that in large urban centres a home birth mother who is registered with the home care program could request a laboratory technician to come in and do the venipuncture tests. However, this is not in keeping with the fundamental premise of continuity of care with which midwifery has been envisioned in Ontario, nor is it likely to be available for mothers outside of large urban centres.

With respect to the future of midwifery, since its inception the IRCM has been aware of the importance of the development of interprofessional relationships. This is especially true given that midwifery is new to the regulated environment. The distribution of controlled acts among the various health care professions will require all of the professions to develop co-operative, collegial relationships that are based on good faith and developed protocols. Through our legislation and public education committee, we have undertaken a course of meetings with the different health profession associations and governing councils. We have used our contacts to initiate consultations with the professions as we develop standards and protocols for midwifery. We intend to continue the development of these contacts in order to ensure the smooth integration of midwifery into the Ontario health care system.

We have also consulted with midwives and midwifery educators from a number of other countries on the issue of interprofessional relationships. These broader consultations inform our view that mutual respect is the hallmark and precondition for the success of the system of controlled acts. As the new and expanded health professions embrace their responsibilities and rights under the Regulated Health Professions Act, the benefit to the consumer and the system will become obvious.


We understand that midwives will work with doctors, registered nurses, registered nursing assistants, laboratory technicians, X-ray technicians, psychologists and other professionals. Depending on the practice sites, midwives will be involved in the management of facilities with these professions. We will be proposing to the new College of Midwives that regular consultation with these professionals be incorporated into its agenda on both formal and informal levels. While we recognize that for some of these professions the entry of a new primary care giver will require adjustment of traditional expectations and familiar working structures, we are confident that the midwife will soon become a valued member of the health care team all over Ontario, as she is already in some communities and settings.

Preliminary work has been done through the office of the midwifery implementation co-ordinator to describe practice sites. It is contemplated that midwives will practise in hospitals, hospital birth centres, independent birth centres, community health clinics, CHOs, HSOs, and domiciliary settings. We await direction from the ministry on the types of funding which will be available for midwives in these settings.

The IRCM ad hoc committee on the Public Hospitals Act has recommended to the Public Hospitals Act review steering committee that the act be amended to allow midwives to admit and discharge clients from the hospital. We believe that the original government intention behind the introduction of midwifery was to include midwifery practice in the hospital setting. Consequently, this amendment will be required coincidentally with the creation of the College of Midwives.

In conclusion, we are pleased to see the support for legislative recognition of midwifery and believe that the functions of self-regulation can be well carried out within the framework created by the bills you are reviewing, amended as we have discussed today.

In closing, however, we wish to urge the government and the Legislature as a whole not to assume that the establishment of midwifery as a regulated profession will be complete once these bills have become law. We still need the establishment of both the pre-registration and permanent education programs, the amendment of the Public Hospitals Act and the small amendments to various other statutes, development of a funding mechanism for midwifery service, and commitment to support institutional development or change that will see to the permanent establishment of the college and ease the integration of midwives into the health care system. We look forward to working with you on the completion of this important agenda.

Mr Beer: Thank you for your submission and also the material you have adjoined to it.

I sense from your presentation that obviously you have a couple of specific points you would like the committee to address in terms of possible amendments, but that on balance things have moved along, the council is going to be established and there will be a real mechanism to direct midwifery in the future.

I wondered if you might just talk a bit about the education. You have mentioned things that you hope will happen, but how do you see the education of midwives evolving? What point are you at with the interim council or has there been able to be much work done on establishing a program and trying to find a place or places where it would be provided? I think you mentioned the university setting, but I just wondered where that was at.

Ms Eberts: There really are two aspects to this issue, and one is the pre-registration program for currently practising midwives. We have been working quite closely with the midwifery integration planning project, which is a consultative group set up and operated out of the Michener Institute to canvass opinion in the community and among the professions on how best to do that integration project. We have, through that collaborative work with them, developed our list of core competencies which we believe to be the foundation of both the pre-registration program and the baccalaureate program in midwifery.

You will find the core competencies in our book of documents which we gave you. We have one final discussion of the MIPP report to have at our next council meeting, which is this month. I expect that we will sign off on it then and it will go on to form the basis for the pre-registration program.

We essentially have no responsibility for running that program, but we have been very deeply involved in consultations with them because it is ultimately the transition college, which is our successor, which has to register all of the midwives who come out of that program. So rather than have them go through it and find that the college will not approve it at the end, we have been involved in the planning.

Mr Beer: Those who are part of the midwifery association or who are currently practising as midwives, would their background stem from another jurisdiction -- Europe, Britain, the United States, or --

Ms Eberts: There is a variety of backgrounds. Some are trained at the university level from other jurisdictions. Some are trained through the regular program of training, whether it is university or not, in other jurisdictions. Some are apprentice-trained here or in other jurisdictions. The purpose is to require that all the midwives who are currently practising be evaluated according to a common core of capabilities. To the extent that any of them need upgrading, that will be done within the context of this program, so that all who finish the program will have reached the same level of competency as we will be requiring for the baccalaureate program.

The baccalaureate program, we hope, will be established on a collaborative basis. Certainly that is what the IRCM has been recommending: that the program take account of the geographical and social diversity of Ontario and be available on a very decentralized basis. Given the small size of the profession, we expect that more than one institution may have to be involved in delivering those programs. We have stressed that the baccalaureate is important because a new profession will have to be very capable and very confident in order to find a place in the health care system, but that there be a very flexible approach to delivering that program, to recognize the cultural diversity of Ontario and to recognize as well that many people who will be interested in it will be people with established contacts in communities that they will wish to return to serve.

The Chair: A question, Mr Hope. One minute.

Mr Hope: Yes, just a brief one. A number of concerns have been brought up by the nursing profession dealing with midwifery in rural Ontario, and I would just like to know for myself, and maybe for the other members of the committee, the difference between what you do and what the nurses do in the delivery of a child.

Mr Jackson: In under a minute.

Ms Eberts: In under a minute, midwives accept ultimate responsibility in a normal delivery. Nurses work under the supervision of a doctor. Some of the comfort that is given, some of the acts that are given, may be the same in some circumstances. It is envisioned that the midwife will be the primary care giver, the ultimate accepter of responsibility for saying what will be done with respect to treatment during the pregnancy, during the labour and during the delivery. That is an essential difference between midwifery and nursing. That is how midwives operate in other jurisdictions.

The Chair: Thank you very much, and thank you for your presentation.



The Chair: I would like to call now Toronto Birth Centre. You have 20 minutes for your presentation. Welcome to the standing committee on social development. I would ask that you begin your presentation now and if you could leave a few minutes for discussion and questions with the committee members at the end of your presentation.

Ms Sutton: I hope you will view my change of seats as a symbolic change of hats. I think it is worth pointing out that one of the strengths of the reproductive care movement in Ontario is the active community involvement of many of us. So I think this bodes well and is a strength of both the IRCM and the Toronto Birth Centre.

My name is Wendy Sutton. I am a consumer member and the president of the Toronto Birth Centre. I would like to introduce you to the other members of the TBC who are with me today: Marianne Cheetham is vice-president of the TBC, a primary care nurse with the South Riverdale Community Health Centre, and a non-practising midwife; Robin Kilpatrick is a practising midwife and a board member of the Association of Ontario Midwives. We bring regrets today from Howard Krieger, who is uncharacteristically under the weather and unable to attend.

We are all members of the board of directors of the Toronto Birth Centre, and we would like to thank this committee for the opportunity to address it.

By way of background, the Toronto Birth Centre is an incorporated non-profit organization comprised of a group of parents, professionals and interested individuals whose goal is to establish a freestanding birth centre in Toronto. We believe that women and their families deserve the choice of experience in childbirth in a setting where birth is encouraged to be a normal and healthy event. We believe that informed decision-making and a choice of care givers are essential rights of clients and that respect for each individual, self-determination and empowerment must be ensured.

We are committed to a model in which clients in the community are involved in all aspects of the management of the centre and we are committed to the pursuit of three main goals. Our goal of service will ensure the provision of a safe, satisfying and individualized birthing experience for women and their families. Our goal of advocacy will promote and support awareness of a healthy birthing alternative for both the public and the centre's clientele. Our goal of education will provide information and education in both formal and informal settings for the public, clients and birth-related professionals, supported by the development of a community birthing resource centre.

On behalf of the board and members of the Toronto Birth Centre we are here today to express our support for the Regulated Health Professions Act. The TBC was formed in 1979. Over those 12 years, we too have experienced "many turns, bumps and delays," to which the minister referred with respect to the RHPA before this committee on August 6. We applaud those who have worked so long and hard on this legislation.

In broad terms, we support the improved opportunities, increased roles and recognition that this legislation offers to women within the Ontario health care system. We support the goal of improved public accountability of professions through increased public representation on councils and discipline panels and through open hearings. We support the intention to improve public protection through implementation of a program of quality assurance and we support the broadened choice of care givers that this legislation proposes as demonstrated by the inclusion of Bill 56, the Midwifery Act. It is this portion of the legislation we wish to address in more detail today.

Since its inception, the Toronto Birth Centre has enjoyed the involvement and support of many midwives. Currently four members of our board are midwives and our board of advisers and general membership boast another dozen individuals who are also midwives. We have a philosophy which is compatible with that of midwifery in honouring continuity of care, informed choice, client decision-making and the appropriate use of technology.

As we approach the day in which we will see the first regulated midwives practising in Ontario in over 100 years, we recognize that birth centres and midwifery care go hand in hand. We are aware that the midwifery scope of practice will include a variety of settings for birth, with parents making informed choices according to their needs. Research shows that birth centres are the choice of many parents. Birth centres will also provide ideal locations for midwives in training and could provide efficient mechanisms for funding midwifery care within the community.

The availability of registered midwives as primary care givers in the development of a truly alternative birth setting will do much to enhance the quality of childbirth care for women in Ontario. It is clear to us that the legal recognition of midwifery and the establishment of freestanding birth centres will benefit from co-ordinated implementation.

One of the greatest challenges emanating from the passage of this legislation will be the way in which professionals adjust to new working relationships. As this applies to reproductive care, we see the need for much dialogue and thought regarding the relationships of physicians, midwives and nurses. The Toronto Birth Centre has always been committed to the involvement of the disciplines of medicine, nursing and midwifery in its operation. As birth centres are developed, we will have the opportunity to develop a unique multidisciplinary model of alternative birthing care that would demonstrate teamwork and reflect consumer choice.

With respect to specific amendments, we would encourage support of the minister's proposed amendments to Bill 56, the Midwifery Act, paragraphs 4.5, 4.6 and 4.7, concerning maternal urinary catheterization, prescribing from a limited list of drugs and the taking of blood samples from newborns. We also endorse the amendments put forward by the Interim Regulatory Council on Midwifery with respect to venipuncture and intravenous therapy. All of these amendments are congruent with the scope of practice of midwifery and enhance client safety by providing continuity of care.

We are pleased to see the interest expressed by government in native midwifery. In keeping with our goal of providing educational opportunities, we have offered our assistance to groups considering the birth centre as one means of implementing midwifery care in their communities.

The TBC has reviewed the preliminary report of the task force on sexual abuse and has indicated support for its recommendations. We look forward to its submission here on August 28 and to the incorporation of its recommendations into the legislation.

We view the RHPA as the catalyst to opening doors to a full range of consumer choice in many areas of health, and in particular in the provision of birthing alternatives. Toronto Birth Centre looks forward to contributing to and being actively involved in that process. We welcome your questions.

Mr Jackson: I am trying to get a clearer sense of the previous deputant, who came to advance the general level of training and access -- not necessarily access, but the general level of training and regulation for midwifery in Ontario. Yours deals as well with the issue of access and the environment in which midwifery can occur. In the absence of any changes to the Public Hospitals Act, what is the likelihood of the development of birthing centres, either associated with hospitals or freestanding? Are they existing now outside of a hospital setting? I did not think they were. And what is your level of access to those birthing centres that are associated with hospitals? We are not giving you the amendments to the Public Hospitals Act. What does that mean to the current practice? The first brief talked at length about how far we are not going as well, so now that I have an opportunity to ask some questions I would like to explore this area.

Ms Sutton: It is a complicated question. It has great historical roots to it as well. At present there are no existing freestanding birth centres and there is clearly a philosophical difference between a freestanding birth centre and those that might function within a hospital.

Up until the last year, the last government had indicated it was going to go ahead with seeing the setting up of birth centres or expressing a proposal call for birth centres under the Independent Health Facilities Act. We are still awaiting some decision on the direction of that. Clearly there is some evidence that we see ourselves fitting more comfortably in more of a community health centre setting. Philosophically that is a little bit more comfortable.

I think from the standpoint of the incorporation of midwifery as a community-based profession as well, there is a comfort level too that is worth considering, but at the moment there are no existing birth centres in Ontario. We are certainly, after this length of time, anxious to see that happen.

Mr Jackson: As someone who sat on the independent health facilities public hearings and participated in the amendments and your presentations in that context, I was aware of the direction and the philosophy that you are pursuing. I am anxious to understand, though, why that legislation will not allow you or does allow you to proceed, whereas we are still hearing the call for the amendments to the Public Hospitals Act. Can you go into a birthing room as opposed to a pre-delivery room in a hospital? Do you have access to that or is that a mutual consent? I would like to get a clearer picture of what midwifery's operating procedures or impediments are currently in Ontario hospitals.

I am asking a second question here in the area of how you interface with the hospital birthing rooms, which are now growing in number in this province, and a lot of hospitals are expanding them. They are in my community, which we support. But I would like to know when a couple has decided to use midwifery services and wishes to have them participate in a birthing room, as distinct from an operating room or pre-delivery room environment. I do not understand what the relationship is there and I would like you to clarify that for me.

Ms Sutton: Let me first clarify that Toronto Birth Centre is based on the development of the facility outside the hospital setting and represents an interdisciplinary model.

Mr Jackson: I understand that.

Ms Sutton: From the standpoint, though, of midwifery -- Robin, you might want to comment on that.

Ms Kilpatrick: Your question is, if this legislation went through and we did not have a Public Hospitals Act amendment, because right now -- I answered this question last week about how midwives are currently working, and that is essentially as support people and advocates at this point, going into the hospital without any recognized role within the hospital. It is hard to imagine this legislation without those amendments and say how a midwife would then work in the hospital setting. If a midwife is acting as a primary care giver, you would envision that then she would continue providing primary care within the hospital setting, if we had those amendments, that the midwife would go in and provide care to her client within the hospital.


Mr Jackson: Just one quick final question. To make it make it really clear in my mind, without the amendments, is it now possible for a hospital to deny you access to the birthing room? That is the straight answer I am looking for.

Ms Kilpatrick: I would say yes.

Mr Jackson: Yes. And that practice can continue in the absence of any amendments. That is your understanding. That is what I was trying to get at.

Ms Kilpatrick: I would believe so.

Ms Cheetham: It is bad PR, but they can do it.

Mr Owens: In terms of the access and cultural sensitivity issues, I am wondering if you have any recommendations that you could make to the committee on how we can, in drafting the regulations, ensure that cultural sensitivity is an issue, whether it is in the native Canadian communities or downtown in other communities, so that people feel comfortable with the experience, as is the intent of the legislation. With the excellent work that your group does, I am wondering if you have any recommendations that you could make to this committee in terms of directions or --

Ms Sutton: I think you have to understand that at the Toronto Birth Centre it is our intention to have every possible access to our facility available to any group, on cultural levels or whatever. That is very much a part of the philosophy of the Toronto Birth Centre.

With specific respect to native midwifery, I think is worth pointing out that although the cultural concerns, the specifics of a setting, say, of native groups compared to something like a Toronto Birth Centre group might vary considerably in their structure, there is no question that the concern for the conducting of childbirth with the surrounding choices that the Toronto Birth Centre and other birth centres want to make available to their clientele is common. The issues of choice in childbirth are common to groups like Native Midwifery and native groups in northern communities, ourselves and other groups across the province, so that we share the way in which childbirth is conducted as a concern, although our specific situations may differ from locale to locale. In that sense, we are unified in terms of having an access to everyone who wants this kind of choice in childbirth.

Mr Owens: Just as a supplementary, to the parliamentary assistant, I am wondering if there is any work going on at this point with respect to amendments to the Public Hospitals Act so that we get the tandem legislation so that these folks will not be in a position to be denied --

Mr Wessenger: I will have ministry staff answer that.

Ms Bohnen: There is an ongoing Public Hospitals Act review that I believe was established under the previous government, that has been continuing in consultation with representatives of the professions, including midwives. I do not know what the timetable of that committee is, but the desired outcome of its work is recommendations for amendments to the Public Hospitals Act.

Mr Owens: Some time within the term of this government, I presume?

Ms Bohnen: I cannot answer a question like that.

Mr Grandmaître: As a follow-up, my question is now directed to the panel. Would you say that without the proper amendments Bill 43 has very little meaning?

Ms Sutton: Which amendments do you refer to?

Mr Grandmaître: I am talking about the amendments to the Public Hospitals Act. Without those amendments, would you say that you have limited powers, and it means very little?

Ms Kilpatrick: That is one way of describing it, that it would definitely limit and interrupt what we have described as the continuity-of-care model that midwifery is based upon, that it would definitely impede the provision of continuity of care not to be able to provide care for clients who choose to have their babies in their hospital but also wish to have a midwife in attendance.

Mr Grandmaître: So Bill 43 is step one in a number of steps.

The Chair: Thank you very much, and thank you for your presentation.


The Chair: I would like to call next the Registered Nurses' Association of Ontario. We ask that you begin your presentation by introducing yourselves. You have 20 minutes, and we would ask you to leave a few minutes at the end for some questions from committee members.

Ms David: My name is Sheila David. I am a registered nurse and I am the president of the Registered Nurses' Association of Ontario. With me are Emily Phillips, also a registered nurse and the president-elect of RNAO, and Eleanor Ross, a registered nurse, a past-president of RNAO and a member of the RNAO's RHPA committee.

This morning your handout is our submission as well as the latest copy of our publication, and in that publication there is an article on nursing specialty relating to neonatal nurse practitioners.

The Registered Nurses' Association of Ontario, RNAO, welcomes this opportunity to respond to the Minister of Health's request for consultation on the Regulated Health Professions Act, RHPA. RNAO has consulted at length with the government and other organizations over the past nine years. In fact, there have been 10 submissions. In our view, the vision of this legislation has been to increase the public's knowledge of and access to health services and to foster parity among the professions. This will forward government policy and address the economic realities of the health care system.

Our positions on RHPA reflect RNAO's mandate. As a voluntary professional association for registered nurses, RNAO's goal is to lead the profession of nursing into full partnership in providing and shaping health care in Ontario. The focus of our activities is on influencing health through health policy, positioning the nurse in the workplace and building partnerships with other health care providers, the government and the public. We provide a forum for nurses at all levels and in all areas of the health care system. Our diverse membership requires that RNAO achieve consensus and balance in defining our positions and policies.

RNAO believes that the principles of public protection and provider equality make RHPA a cornerstone of health legislation in Ontario. This legislation will affect existing and proposed legislation, as well as institutional and community structures. It is imperative that RHPA not only reflect current practice, but also provide for the evolution of health services and provider roles.

RNAO supports this legislation and commends the consultative process undertaken to bring RHPA into law and practice. However, having reviewed the legislation, RNAO believes that several proposals are not congruent with its overall intent. Indeed, they may well hamper the achievement of its full potential. These proposals may arise from historical behaviours and relationships which, while still having considerable influence, are no longer appropriate, particularly for the future during which this legislation will be effective.

The three major proposals that concern RNAO are those dealing with: first, communicating a conclusion; second, "on the order of"; and third, use of the title "nurse." These will be highlighted in today's presentation. RNAO also recommends additional changes to the omnibus section, the Nursing Act, 1991, which are included in our written submission which you have received today. We would be pleased to discuss our recommendations today as well as in the future.


"Communicating to the individual or his or her personal representative a conclusion identifying a disease, disorder or dysfunction." This proposal is the first that RNAO finds incongruent with the intent of the legislation. It does not reflect parity of the professions within their respective scopes of practice. The intent of the legislation is that the public have access to sufficient, accurate information in a timely manner to enable them to choose practitioners, settings and interventions. It would seem logical that practitioners in the context of their scope of practice can communicate the findings of an assessment or a dysfunction to a client.

Although much effort has gone into developing this wording, it still reflects an attempt to limit diagnosis to five professions -- chiropractors, dentists, physicians, optometrists and psychologists -- even though a number of other professions also make diagnosis appropriate to their own scopes of practice. For instance, nurses make nursing diagnoses which are not to be confused with medical diagnoses. Although a significant body of literature and research confirms the existence of the value of nursing diagnoses -- and we have included that in our submission -- this proposal as it now stands denies the nursing profession the right to include nursing diagnosis as a controlled act.

Other professions also communicate a conclusion about dysfunction based on knowledge and their scope of practice. For example, we heard this morning from the physiotherapists.

RNAO recommends, then, that the acts recognize diagnosis or communicating a dysfunction as a controlled act for each profession within its scope of practice.

Under the Nursing Act, 1991, "on the order of a qualified person": This is another proposal which RNAO finds incongruent with the intent of the legislation and which has real potential to hamper the delivery of appropriate and timely health care. Even today, orders are written by a variety of health professions. Orders are directions regarding care and treatment of a patient. They are not directions to a health care provider. Scopes of practice determine which profession will carry out which aspect of patient care.

Currently the standards of nursing practice indicate when written orders must be on record for nurses. Therefore, this wording is unnecessary. Also, this wording perpetuates the perception that one profession is subordinate to and takes orders from another.

In addition, it is essential that this legislation allow for the continuing evolution of practice. This wording may well inhibit the evolution and adaptation of practice to new circumstances which will certainly arise during the life of this legislation. That is reflected in that article you received today.

RNAO therefore recommends that "on the order of a qualified person" be deleted.

On the issue of the use of the title "nurse": The third example of incongruence concerns the use of the title "nurse." The major aim of this act is public protection, involvement and choice. Clarity of title is fundamental to public understanding of who is who and who does what. All practitioners regulated under this act are registered. Therefore, "nurse" is a unique designation. It should be limited to the registered nurse and not extended to the nursing assistant. Sharing the adjective "nursing" with registered nursing assistants is appropriate, as this form makes it clear that RNAs work with nurses, both independently and interdependently, but are not nurses.

Nurses work in diverse settings and are situationally responsive to their client needs. Practice may be in a hospital, the clients' home or workplace. Nursing offers a wide range of care from health promotion to intensive or palliative care in urban, rural and isolated settings. Depending on the setting, the availability of other providers and clients' needs, registered nurses function within their knowledge and their scope of practice.

It is imperative that the public and other providers know who is a registered nurse. It is confusing for the public and other providers to allow four other categories of "nurse" in the act. Level of knowledge and accountability must be clearly indicated by title.

RNAO therefore recommends that the use of the title "nurse" be limited to registered nurses so that the public and other health practitioners are absolutely clear about who is a legally qualified nurse.

The Regulated Health Professions Act is important legislation which enshrines public protection and provider accountability. RNAO supports these intentions and looks forward to working with the public, the government and other providers to ensure that current and future health care practice is accurately reflected in the act.

Thank you for your attention to this presentation. We would be pleased to discuss our three priority issues as well as quality assurance and managing labour.

Mr J. Wilson: Thank you for your presentation. I tend to be very sympathetic to your suggestion that we delete "on the order of a qualified person." It seems to me when you put it in layman's terms it comes across as a bit of an insult and could very well restrict the independence of nurses even further than certainly this act was intended to do.

I want to ask the parliamentary assistant about the ministry's thinking behind the phrase "on the order of a qualified person," given the testimony we have heard where standing orders and protocols are often in place and the terms of practice as established by the nursing profession itself cover the situations where orders are required.

Mr Wessenger: I will let ministry staff reply to that.

Ms Bohnen: The review believed that within the health care system, for hazardous activities, there had to be clear authority for the provision of the service to the patient. That health professional who determined what treatment should be provided, where that treatment involved hazardous activities, had to be someone who was fully qualified to make the treatment decision, someone who could be accountable, and there should be one person responsible for the patient's care so in fact orders for patient care do exist. If you accept that then the issue becomes, where does the legal system mandate such orders, the review believed it should be written into the legislation which says that in this case nurses may perform these hazardous activities, but only where there is an order.

I think we have heard from the nursing groups -- at least from RNAO this morning -- saying it is unnecessary to incorporate that in the act because nursing standards of practice provide sufficient guidance to nurses as to when an order is necessary. That simply was not the review's opinion. The review felt it was a matter of sufficient importance to incorporate into the statute rather than leave it to nursing standards of practice, which to date have not even been incorporated in regulations.

Mr J. Wilson: We also heard from a nurse who was employed at a Toronto hospital indicating that in many wards there are not any standing orders. We have also heard stories about the retroactivity of orders and the day-to-day conduct of affairs on hospital wards.

Ms Bohnen: That is their view. I think later on today you are hearing from the Ontario Hospital Association. You may want to ask them from the hospital administration perspective how they view this issue.

Mr Cordiano: I am interested in asking you about the recommendation with respect to the use of the title "doctor." What you are suggesting here is that prepared nurses -- I am assuming nurses who hold the PhD degree, is that correct?

Ms David: There are some nurses in the province, yes.

Mr Cordiano: If the use of the term or title "doctor" is extended to PhDs, you would have perhaps a name tag indicating that this person would be then referred to as "doctor of nursing," I suppose, or just simply "doctor." I am assuming that person would still be, in his or her field such as nursing, practising nursing with the title "doctor." In the public's mind, would that not create a discrepancy between, say, the person who is a PhD and then is referred to as "doctor," and a nurse who is an RN? Would there not be a distinction made there by the public as to the level of qualification with respect to the kind of service being provided in nursing, shall we say?

Ms Ross: This piece of legislation to us is very visionary. It is looking to a different way of delivering services in the future. If you look at the term "doctor," the term "doctor" for a PhD is used by many disciplines. It is an academic term. However, traditionally within our system the physician has taken on the title "doctor." As we move forward and we have a variety of health providers -- you know there are many and you are hearing from them, and all of these different groups specialize and advance and require more academic training and so on. They will achieve the doctoral level. I certainly appreciate where you are coming from with the confusion. For example, nurses now have RN, PhD, because PhD is the formal title, so those kinds of terms could be there. There is certainly no intent for nursing or any other provider to be seen as the physician. But we feel strongly that if we have achieved those levels of standing and academic positions, we should be able to have that title.


Going back to the visionary statement, we keep going back to the hospital setting and the traditional view of someone being responsible and so on. But if you look in the future, there still will be hospitals, but a lot of the care we are going to provide is going to be in the community and will be delivered very differently. One hopes, at least in our view of the future, that the patient, the client, will be able to access a physiotherapist or a social worker, whoever, directly, and not have to go through and be referred as the traditional system has been. We are trying to look at this as visionary and recognize that some of these kinds of statements, and we have referred to this, as we move forward and shift how we are delivering care, can be hooks that really hamper the potential of this legislation.

Mr Cordiano: I am sympathetic to the notion that having achieved that level of academic standing -- I am not opposed to the use of the term "PhD." I am trying to grapple, and I think this committee is, with the use of the actual phrase "doctor", and how that might create confusion in the public's mind with respect to differentiating between a variety of health care professionals. We are just trying to deal with that fundamental difference between who we designate as "doctor" and the use of that term as a restricted title.

Ms David: I think your concern is very valid. The concern we have also is the education of the public and taking them forward with this new terminology that is coming to them.

Mr Owens: A quick question to the parliamentary assistant: I requested yesterday a note or a response with respect to the issue of standing orders, where and how they are applied, and the issue of retroactivity. Are we going to see that in writing or will we have a response later on today?

Mr Wessenger: I will refer that to staff.

Ms Bohnen: I am sorry. We did not realize you wanted an answer today specifically about the retroactivity of standing orders. What we have begun to prepare is more comprehensive information about standing orders and other ways in which authority is provided now in hospitals, nursing homes and in the community for nurses to practice. If you require a quick answer, specifically on retroactivity and standing orders, we can try and get that quickly for you.

Mr Owens: Perhaps if you can include that in the package.

Ms Bohnen: We certainly will include it but if you wanted a quick answer just on that point, we could try to have our staff get that answer, or can you wait?

Mr Owens: I think we can wait. We have waited nine years.

Mr Beer: The issue of diagnosis and assessment has come up in a number of cases. I just wonder if you could help the committee. Pardon my ignorance, but when you are making a distinction between what you referred to as a nursing diagnosis and a medical diagnosis, could you give an example of what you mean by that?

Ms Phillips: Say we have a two-month-old infant who is ill. The doctor may make a medical diagnosis of iron deficiency. By doing lab tests they find this child has an iron deficiency. The public health nurse may be working with this mother and infant and may find out that the mother has put the child on cow's milk instead of continuing with formula. So it is a knowledge deficit of the mother that has caused this child to become deficient in iron. The public health nurse may also find, with her assessment of the mother and infant, that the mother cannot afford formula because of her socioeconomic level. It may be she is a single mom, a young, inexperienced mother.

The nursing diagnosis takes in the whole picture of the mother-infant setting. It is a nursing diagnosis versus the medical diagnosis of iron deficiency for which the physician would order an iron supplement. The nurse would work with other health care providers to raise the mother's level of knowledge concerning the cause of the illness.

Mr Beer: In your view, that kind of diagnosis would be clearly understood in other jurisdictions as well, if we looked at the United States or Britain or Europe, as something people understand and recognize as a nursing diagnosis?

Ms Phillips: I think maybe the problem with understanding is that we picture "diagnosis" as a medical diagnosis, whereas in our nursing practice now we make nursing diagnoses which are distinct from medical ones.

The Chair: Thank you very much for your presentation. We appreciate your appearing this morning before the committee. I would point out, as I have on other days, that over the course of these hearings you should feel free to communicate with the committee in writing and add to your very excellent brief any information you think might be helpful for committee members.


The Chair: I would like to call now the Board of Directors of Masseurs of Ontario. I welcome you to the standing committee on social development. I would ask that you begin your presentation by introducing yourselves and, if you would, leave a few minutes at the end of your presentation for questions from committee members. You have 20 minutes.

Mr Shekter: Thank you, Madam Chair. My name is Richard Shekter. I am legal counsel to the Board of Directors of Masseurs of Ontario, and I will allow the two ladies beside me to introduce themselves.

Ms Cowall: My name is Emily Cowall and I am the chairperson for the Board of Directors of Masseurs.

Ms Colborne: Margaret Colborne. I am the past president of the Ontario Massage Therapist Association.

Mr Shekter: The committee, I understand, has a copy of my correspondence of July 15 which summarizes the concerns and the position of both the board and the OMTA in connection with the proposed Bill 52, and the omnibus legislation. I do not propose to read it. I think I will just summarize our position as follows: First of all, anyone who is familiar with the Drugless Practitioners Act, and I am sure you all are, can imagine how welcome this new legislation is. The DPA is a complete disaster. It has been for years, and it makes it almost impossible to manage anything. We have been labouring under that for years and, hopefully, with this process being finalized, we will finally get an act that makes some jurisprudential sense and provides an element of fairness to the procedures that are, right now, established from 1919, and have not been amended since.

With respect to the procedural issues, we do not have any comments. We are content to leave the criticisms you have heard to the other regulated groups. We are content to stand by the positions of virtually anyone else. We do not have serious problems with them. They are so far in advance of what we have been dealing with for years that there is no point. We have a Rolls-Royce now, and if you want to make it a Rolls-Royce with a Bentley sticker, please go ahead. It is not our problem.


Mr Grandmaître: Can we quote you?

Mr Shekter: Sure, but under my assumed name. With respect to the issues we do have concerns about, we have two essentially. The first is the protected act definition, not surprisingly, of communication, and the absence of a protected act that deals with rendering services on the prescription of a physician or a qualified person. We will make a submission about that. We also have a submission, and it is a very practical one, dealing with the composition of council.

Those are the main areas I am going to deal with. Let me start with the composition of council. Under section 5 of the amended Bill 52, there is a requirement that we have, I think it is seven, and not more than eight members. We do not have a problem with that. But there is also a provision that we have five public members.

The reality is that we have difficulty getting public members interested in sitting on this board now. Historically it has been extremely difficult. We are not the College of Physicians and Surgeons of Ontario. We do not have a lot of snappy hearings and public things, and people, quite frankly, are simply not that interested.

Anecdotal: In October a member of the board ended her term. On October 10 we wrote to the ministry and said we needed a public member. They said, "Fine, we will get on to it." We said: "We have a hearing scheduled. It is a sexual assault hearing, a very serious case. We cannot proceed without a quorum. You have to help us out." "Fine, we hear you."

Two months later, in December, they phone us up to say, "Sorry, we cannot locate anybody." We say, "We have to have a hearing." "Sorry, we cannot do anything about it. Why do you not see if you can find somebody?" We spend a month. We find two names. Then on January 22 we give them two names. It takes six months to get the person appointed.

In the meantime, the hearing is in abeyance and the complainant is going crazy. I keep explaining to the complainant, "I am sorry, but we cannot do anything about it. We cannot have a hearing." Finally the ministry bequeaths us a public member, and we can start our hearing. By then we have to give notice because we do not know when the member is going to be ready, so we start the hearing in this office.

That is just to find one. You want us to find five. We do not mind having a maximum limit, but we really are concerned that if you do not reduce the minimum to, say, two, we are going to find ourselves in the position we were in, and have been in over the last five years. It is not our fault. We can get our members, but we cannot get public members interested, if history is any indication.

I would strongly urge that you reconsider that. We would like a maximum of five. We do not have a problem with that. It is the minimum that will probably stop us from operating at all, in the corresponding amendments to the other portions of the regulations that would require certain numbers. That is all I have to say about that.

Let me deal with protected acts. We are asking for two, or more to the point, if you are going to keep communication, we are asking for two; if you are going to eliminate that, we are asking for one. The first one -- it is almost a flip side of what you just heard from the nurses -- is, "the rider on the order of."

It has been our position from the beginning that if you are interested in protecting the public, it makes no sense at all to have the physician prescribe a specific therapeutic modality of massage therapy, but not protect the public from having persons who are not trained in massage therapy and who are not regulated carry out that order.

The way the act is drafted now, if there is a specific kind of therapy that is prescribed, anybody in the world can do it. How that serves to protect the public interest, I do not know. I have never had a satisfactory answer. I have had meetings with the HPLR people for the last four years and we have agreed to disagree, and I urge the committee members to consider it.

There is no reason why, as a protected act, if a physician or a dentist or a chiropractor diagnoses and prescribes something -- we are not necessarily insisting that it go beyond the physicians. Frankly, we do not know why people who are not licensed ought to be permitted to do it, because they cannot, by definition. They have not been trained, and it is potluck. They may or may not be able to deal with it. We see no public interest served by not having it. It is as simple as that.

Communication: I am sure that I am not the first, and I certainly will not be the last, to deal with this particular problem. Simply put -- and I have set out to some extent in my letter what our concerns are -- the way it works, it says in effect, if you flip it around, "It is an offence to communicate to the patient, or his representative, a conclusion identifying a dysfunction as the cause of symptoms." In other words, you cannot tell a patient why he hurts.

Massage therapists are in the business of alleviating pain. That is what they do. What you would have us do is assess, because we have to figure out why the patient is there and what is causing the pain. We can do the work, but we cannot tell them why. We have the present chairman of the board and the past president of the OMTA here and they can, if you wish, in question period provide you with anecdotal information about what a patient encounter is like.

Just imagine, if you will, somebody coming in off the street. They have not seen a physician. They have a terribly sore neck and shoulder. The massage therapist does the assessment, which includes a physical examination, realizes that the entire back and upper quadrant is in spasm, and says, "Now I am going to do the following series of things." The patient, naturally enough, says, "But why am I hurting?" "I am sorry, I cannot tell you that." "What are you going to do?" "I am going to do this." "Will it help?" "Sorry, I cannot tell you that."

With all due respect to the rationale of this system that is supposedly in place, which is, as I understand it, to prevent people from making diagnoses upon which people will rely, to the exclusion of the medical practitioner or another qualified person, it makes nonsense of the notion of informed consent. It is over-broad and, if taken literally, it could cover the situation where a massage therapist, in response to a request for a medical report by a lawyer acting for a motor vehicle accident plaintiff, would be prohibited from communicating conclusions which they do every day, because it is going to be relied upon.

That is how far-reaching the language is, notwithstanding that everybody says, "It could not possibly have been construed that way." I suggest to you that it can. In every day of practice, particularly in massage, they get letters from lawyers saying, "Listen, he has been injured and we want to know why it is hurting and what you are doing to alleviate it." Under this, is it going to be relied upon by the personal representative or by the patient? Yes. Is it a conclusion as to identifying the dysfunction as the cause of symptoms? Yes.

It gets more practical. The law of informed consent and the whole consent, the treatment legislation, which is a major threat to this current government and which we wholeheartedly agree with, seems to us to fly in the face of the spirit of this particular prohibition. I have given some indications in my submissions as to why we say that, and anecdotal information.

Simply put, you cannot deal with the subject. A doctor, as it happens, and it happens quite frequently, sends a patient with a diagnosis and then requests a specific modality of treatment. Part of the standards of practice require the massage therapist to reassess the patient to determine whether (a) there is an agreement with the assessment of the physician, and (b) whether the modality treatment prescribed is or is not contra-indicated, based on the assessment of the practising massage therapist. If that happens, and it happens quite frequently, they are stuck. They cannot then say, "Look, I cannot go ahead and do what your doctor wants me to." "Why not?" "I am sorry, I cannot tell you." This makes nonsense.

Finally, we have no problem with the scope of practice. We never did. We understand that other groups have made submissions. We do not intend to make any unless there is a response to a particular inquiry, and subject to that, the questions you may have.

Those are our submissions. In the materials we have given you there are some exam questions that are routine in every exam, going back for 50 years. They talk about the kinds of things massage therapists are trained to do and the kinds of questions they are asked to describe patient encounters. You will see that communication is sort of the heart of it all.

You will see the standards of practice. At pages 4, 7 and 10 of the standards, they talk about the requirement of communicating and having a meaningful interaction with the patient. You will see that. You will also see medical legal requests for reports, and the types of reports we respond with. You will see that if you read that literally, that is a prohibition under paragraph 26(2)1. The massage therapist is guilty of an offence.


Mr Hope: Thank you for the presentation. The part I want to look at is the public members. You talked about having a hard time getting one, let alone five to serve. I would like to pose a question to you. Is it maybe that members of the general public do not want to participate in these groups for the simple fact that they are not heard and do not have the voice they should be having, that they are just there to rubber-stamp situations, to be the token figures of a board or a governance, or whatever? Is that maybe what the perception is? I hear what you are saying. You are looking for the government to ensure that the bodies will be there. At the same time, we are looking for those governances to make sure they have a responsibility, number one, to listen to the members of the general public who are an active part of it. It is a dual role, in order to make sure.

I have sat on a lot of volunteer boards before and I am not about to be there to rubber-stamp and I am not about to go -- you said you do a lot of arguing too. I do not think a lot of us are there to argue. We are there to make progressive steps.

Mr Shekter: I can tell you that our experience has been that the primary response is simply a lack of interest, because massage therapy, to the lay public, in layman's terms, is boring. There is not much going on. It is not a high-profile job. People just are not interested. The persons we do have are extremely active. One of the last ones was the chairman of the board. I suggest to you that if you want to talk about rubber-stamping, it is more likely to happen at the College of Physicians and Surgeons of Ontario, where there is a highly technical component to what they are doing, than in massage therapy cases where the bulk of the work in the board's or the council's perspective is dealing with matters that are applicable to laymen and experts alike. There are a lot of things in the section on propriety that are coming up, given the nature of the profession. They have as much input as anybody. That has never been a criticism.

Mr Hope: Would it not serve more as a positive approach to having more members of the general public there for the simple fact of public awareness and making sure the roles you do are more communicated to the general public?

Mr Shekter: Understand what our position is. Our position is we welcome having as many as we can get. But our concern is that you have put a minimum of four. We had trouble getting one. You may stop us from practising. I can tell you that the board intends to have as many as it can get and always have a full house. They do not have to worry about it. We are on the flip side where we want as many as we can get and we cannot get any. If it took us 10 months to get one, God help us when we need to have four. That is all I am saying. Do not reduce the maximum number. Reduce the minimum so that at least we can operate and have a quorum, statutorily authorized, because if you make us have four, given history, we may not get it. It is not our fault.

Mr Beer: I would like to come back to the question on communicating. Can you tell us, at the present time, under the existing legislation and regulations, is there any restriction on what you can do or say to a patient?

Mr Shekter: No, the only restriction that by extension applies is a prohibition against engaging in an act that is beyond the scope of your expertise. I, as a lawyer, tell you that would probably include purporting to diagnose a cancerous lesion on a back. But there is nothing that prohibits communicating. In fact, quite the contrary: I prosecute, on behalf of the board, members who are in violation. It would be substandard practice not to appropriately communicate an opinion and assessment and a cause of dysfunction to a patient, rather than the other way around.

Mr Beer: I appreciate the point you make in your letter about the meaning of dysfunction and disorder, because I think that is something we also have been seized of, and others have mentioned this, in trying to define what those terms mean. Taking it from another angle, is the limit on your communicating partly related to a determination that the training that masseurs have does not entitle them, or does not give them the necessary expertise, in effect, to be able to diagnose conclusions? Is that part of what the problem is here, to the extent that you are aware of one?

Mr Shekter: We have been using the verbiage for the last five years in HPLR and making, to some extent, artificial distinctions between assessment and diagnosis. The example of a nursing diagnosis, in my view, is more properly an assessment than an evaluation. But casting the language aside, my people are extremely highly trained in physiology and modalities of therapy. They are in a position to draw those conclusions and communicate them. In fact, they do them every day. If you saw their course curriculum, it is a two-year course. It is extremely rigid. It has much of the same kinds of course hours in physiology and related subjects that physicians do.

We do not belittle the ability of the members to do certain things. What we do say is that there is a line between medical and physiological dysfunction and we wish to maintain that distinction but within the scope of our practice. If we cannot communicate, we cannot practice.

Mr J. Wilson: Thank you for your presentation. The first point you make in your letter of July 15 to the committee concerns, as I understand it, current practice that patients have to be referred to a massage therapist.

Mr Shekter: No, not necessarily.

Mr J. Wilson: You can be a primary care giver?

Mr Shekter: And often are.

Mr J. Wilson: Then I am not quite sure I understand the first point here.

Mr Shekter: The first point is simply this: Where a physician -- it happens primarily in the major metropolitan areas where the majority of the massage therapists are -- does prescribe a modality of therapy, it seems to us nonsense to be able to have unlicensed, unregulated persons attempting to carry out something that is medically and therapeutically precise and that you require training for, and there is nothing in the act that prohibits it.

Mr J. Wilson: Have you a suggested wording or section for that?

Mr Shekter: We discussed it at length. Simply, it would be a prescribed or controlled act for persons other than regulated professions to carry out directives or prescriptions made on the order of duly qualified medical practitioners, something as simple as that. If you just say, "Well, go to a massage therapist," that is one thing, but if you say, "There is a prescription and it is signed and you need" -- there are certain situations, for example, where doctors give those prescriptions to patients and it is contingent upon there being an insurance coverage for that service. To have unlicensed people do it seems to me to be nonsense and serves absolutely no public interest.

The Chair: Thank you for your presentation. We appreciate your coming before the committee today. If you have any further information for the committee, please feel free to submit it in writing.


The Chair: I would like to call now on the Ontario Chiropractic Association. I would ask that you come forward and introduce yourselves to the committee. You have 20 minutes for your presentation. We ask, if you would, to leave a few minutes for questions from committee members. We have all received the extensive brief you have submitted for the committee. I would ask you to begin your presentation now.

Ms Koch: Good morning. My name is Roberta Koch and I am the president of the Ontario Chiropractic Association. At this time, I will introduce you to our representatives here this morning. We have Dr Lloyd Taylor, our legislative representative to Queen's Park; Mr Peter Waite, our executive director; Mr David Chapman-Smith, our legal counsel; and, finally, Dr Robert Haig, immediate past president of the association and our current chair of the RHPA committee. Dr Haig will now make the presentation to you, followed by David Chapman-Smith. Then we will be prepared to answer any questions you might have of us.

Dr Haig: While there are many aspects of the RHPA that the Ontario Chiropractic Association would like to applaud, the amount of time we have before you today simply does not permit us to dwell on the many positive and progressive aspects of the legislation. Suffice it to say, as you have heard from others, this legislation stands as one of the most comprehensive and progressive pieces of legislation in the world. Congratulations are due to all those involved in its development.

Today, we want and need to focus the committee's attention on the very important concerns our profession has regarding the proposed scope of practice for chiropractic that is in Bill 46.


The members of the committee may already be aware that while most of the professional groups involved in the review gave their written sign-off, their agreement on their scopes of practice, the OCA did not. The OCA did not sign off because the proposed scope of practice developed by the review team, and agreed to by the Ontario Medical Association but not by us, reduces the existing scope of practice of chiropractors and reduces the availability of services to the public. It does this by removing the existing right and the existing duty of chiropractors to diagnose disorders of extremity joints: elbows, knees, shoulders. More important, it does this without any justifiable cause whatsoever.

The HPLR process served as a very successful vehicle for many groups in ironing out their differences over the past nine years. I regret to tell you that in our situation the differences are not resolved. We are counting on the members of this committee and each of the three political parties to look very closely at this issue and to resolve the differences during the clause-by-clause review of the legislation. As far as chiropractors are concerned, the outcome of your deliberations on this point will have a major impact on the place and value of chiropractic care within the health care system of Ontario in the future.

I think it is fair to say that most members of this committee are aware of some of the history of the struggle that our profession has had in gaining regulated acceptance in this province and in a number of other jurisdictions around the world. Today, of course, chiropractors are well accepted by the public. Indeed, we are the third-largest primary health care profession after physicians and dentists.

We have grown not because we have been accepted by the more traditional elements within the health care system, but rather because our treatment modalities have proven to have effective outcomes. We have grown because consumers vote with their feet. Most of our patients are referred to us by other patients whom we have treated successfully.

Over the years, because of the increasing level of public acceptance and because of the growing body of scientific evidence that supports the efficacy of chiropractic, government has tended to recognize that level of consumer acceptance. Indeed, when developing the public health insurance system in Ontario, the legislators, in response to public demand, included chiropractic services among those paid for under the Ontario health insurance plan. More recently, the Ontario motorist protection plan enhanced access to, and freedom to choose, chiropractic care. So we have gained acceptance and we have progressed.

However, in the legislation that is before you now you will see that in our profession's case the HPLR process has actually been used to reduce the traditional scope of practice of chiropractic. We did not enter into this process with any intent to increase our scope of practice, but we cannot accept a net reduction in the scope that this proposed legislation includes.

It is important that the members of the committee understand that it was a fundamental principle of the HPLR process that no existing scope would be reduced unless there was convincing evidence of lack of qualification and harm to the public. During the course of the nine years of this review, no one at any time produced any evidence of that sort, anything that could be used to justify the removal of diagnosis of non-spinal joints.

Current legislation, education and training all include the ability of chiropractors to treat all joints of the body. You heard yesterday from the chiropractic college, which explained in some detail the education in that regard. The proposed scope in the legislation you have before you does not provide for the diagnosis of non-spinal joints. We are appealing to the common sense of the legislators on this.

Just think about it. The diagnosis of disorders of spinal joints is at least as complex and as complicated as the diagnosis of non-spinal joints, and it is quite illogical to have one without the other, but for some reason that has not been revealed to us, the OMA has opposed the inclusion of diagnosing extremity joints within our scope of practice.

The removal of this important part of practice affects the public in two ways. First, it reduces their level of protection. Currently a chiropractor has a legal duty to provide a full diagnosis. Under the proposed law, the chiropractor has a lesser duty than that. Second, it limits the freedom of choice, and that goes against the whole intent of this legislation.

I am going to ask Mr Chapman-Smith now to give a case example that will illustrate for you the effect that the legislation, as proposed, would have in Ontario.

Mr Chapman-Smith: I will present a case example which illustrates this and then refer to the current state of the law, because that is obviously crucial. I have been here during hearings when it has been suggested that the law may not be as we have stated and I want to get that clear before you today.

But first, to look at the case, you will see in the submission attached as appendix C -- the appendices are in green at the back of the submission; at least in most of them, I think. Some of them may be white, but you will see at the back there appendix C, and it is to that statement I now refer. That is a statement by Paul Peschisolido, who is with us today sitting in the front row. I would have asked Paul to come forward and read this statement if there was more leisure and more time, but I am going to whistle through it a little bit more quickly, ask him to confirm its accuracy, and he will be available for questions. As we read this, I invite you to consider that what he describes here is the health care system as you would like to see it in Ontario with the degree of co-operation, flexibility and freedom of choice such as is the intent of this legislation.

Paul states that he plays in the centre forward position of the Toronto Blizzard Soccer Club and the Canadian National Soccer Team, and he has played for Canada since the age of 15 on those various teams listed there and now the national team.

"I have had a number of leg injuries during my career, and am available today because I am still recovering.... Leg injuries are frequent in soccer. I wish to explain briefly how the Toronto Blizzard sports medicine team works, with particular reference to the role of Dr Robert Gringmuth, a chiropractor, in the diagnosis and management of injuries.

"For the three years I have been with Toronto Blizzard the sports medicine team has been led by Dr Gringmuth. He works in close association with our consultant orthopaedic surgeon, Dr Geoff Lloyd...other medical consultants such as Dr Tom Fried, and team therapists and trainers.

"When someone is injured in play in Toronto the standard arrangement is that he is given temporary assistance at the field...then sees Dr Gringmuth for a full diagnostic workup and treatment.

"During early 1990, for example, I sustained a quite bad right knee sprain. I saw Dr Gringmuth at his office and he examined me and took X-rays to rule out bone fracture. He diagnosed the problem as a right medial collateral ligament sprain in the knee. He treated me with ice, interferential therapy and mobilization, and then directed my rehab program.

"Sometimes a player will be taken directly to Dr Lloyd at the Toronto Western. This would be in cases, for example, where initial assessment at the field is that a cast will probably be necessary" -- and obviously chiropractors do not do that.

"My current injury falls into this category. I sustained a severe left ankle sprain.... My ankle was X-rayed" -- at the hospital and there was a cast immediately arranged -- "and from there I was referred to Dr Gringmuth," who is the team doctor and the chiropractor. "He then saw the X-rays and explained I had a third-degree sprain without bone fracture. My ankle was in the cast for about three weeks, and for continued daily rehab Dr Gringmuth has referred me to physiotherapy at the Durham Orthopaedic Clinic which is near my home in Pickering.

"I am told that the proposed new law might not provide for the detailed diagnosis and management of injuries such as mine by a chiropractor. The experience for me and my teammates, and obviously the Toronto Blizzard management, is that Dr Gringmuth has as much understanding about these injuries as anyone and runs a first-class sports medicine team."

Just for the record, Paul, I will ask you to confirm that is accurate?

Mr Peschisolido: Yes.

Mr Chapman-Smith: Thank you. This is what happens under the present law. We can look first at the freedom of choice that Paul himself has, but I want to focus for a moment, because this goes to the heart of it, at the Toronto Blizzard Soccer Club and its management. At the moment, chiropractors are authorized under the law to diagnose these problems. They have a choice. They could have heading their team a physician or a chiropractor. They have found a chiropractor with whom they are happy, who is doing an excellent job for them and he runs that team.

There is no question that under the law as proposed they could not do that. They could not have expensive, professional stars at risk of injury and have their whole team run by someone where it is clear under the law that he is not authorized to diagnose those problems. I think that is apparent to everyone.

From that, then, I want to turn to what the current law is and deal with this very briefly, again because of time. If you go back to appendix B you will see a summary of the current law on appendix B-1, and then attached to it the actual provisions of the legislation.

It has been suggested in a briefing document you have been given that chiropractors are not currently authorized under the law to diagnose extremity problems. That, in my humble submission, is completely wrong. What the Ontario Chiropractic Association proposes is that if there is any doubt whatsoever on that issue, an independent legal opinion be obtained from any senior lawyer in Ontario. We would nominate a lawyer, the ministry could, and they could nominate an independent person to give an opinion on whether chiropractors under the current law are entitled to diagnose.


The summary of the present law is there. The Drugless Practitioners Act itself does not have a scope of practice. It is very old legislation; 1920s. There has been case law since. It is a system of treatment. The body of the legislation and the case law makes it absolutely clear that chiropractors have this right under the current law. At the bottom of appendix B-1 is a summary of the current position. This is a legal opinion obtained from Blake, Cassels and Graydon in 1988. The two lawyers involved there were John Brownlie, a respected senior lawyer, and also John Ronson who we involved because he was executive assistant to Mr Elston when he was Minister of Health and was intimately familiar with these issues. You will see what they have to say and how they say the public will be ill served if this goes.

Why is there a problem then? Why is this not in the scope? The OCA says quite clearly it is in the scope because organized medicine has opposed it, but without ever being prepared to put the grounds for its opposition in writing or present a case. In the nine years of the HPLR we have never been given anything overtly, in the open, to argue this case. In a briefing document you have, which is attached as appendix E, and the precise page is E-11, physicians argue chiropractors are not qualified. How I wish, with respect, I could have a day to cross-examine any of these physicians on the stand so you could get at the truth. Many physicians, including the ones that work with Dr Gringmuth, obviously disagree. But here you have the heart of the problem and because of time I will not be able to take it further than that.

I merely conclude by saying that we have emphasized today one of the various important issues. The other issues appear in the executive summary and in the text of the brief. I know Mr Beer was asking questions some days ago about a harm clause and about the balance of diagnosis and assessment. We have what we think are constructive and helpful suggestions in that area, but obviously there is not time to get into all that today.

If you look at appendix A you have there, both as to scope of practice and as to authorized acts, exactly what is in the proposed law and exactly what the proposed amendments from this association are. It is submitted that those are conservative, uncontroversial and we look for your support in those.

The Chair: Thank you very much for your presentation. For the information of the committee, I have had a request for Mr Wessenger to ask a question. I will place him first on the questioners' list and then continue with the line of questioning.

Mr Wessenger: I am just wondering if you could provide us with a copy of the opinion from Blake, Cassels and Graydon on this matter.

Mr Chapman-Smith: Certainly. I have one today I will leave with you.

Mr Wessenger: I would like a copy of that. Thank you.

Mr Jackson: Yesterday, as you indicated, we heard from the college, and I made several statements then with my own experience as it relates to this issue of diagnosis of joints other than those that emanate from the spine. I wonder if you could share with this committee what you feel the differences are, because my case story is similar to our guest's, and perhaps you as professionals could indicate the difference, if any, and why perhaps the government is moving in this direction.

Dr Haig: That is the point I made in my opening comments, that there really is not a difference and that is why we find it illogical that one should be omitted.

Mr Jackson: Does this not have serious implications for the Workers' Compensation Board as well? I have cases of lifting problems associated with the shoulder, the elbow and the wrist. My injury was a baseball injury, but it is quite a common industrial accident in terms of its manifestation. Yet it occurred to me last night, as I was thinking about this, that this also includes several of my constituents who have come to me with this kind of injury. Being right-handed, I was okay, but the physician had me so bound up I could not do a damned thing and I was having problems with my whole side of my body as a result of a wrist injury until my chiropractor relieved me in one afternoon of all the pain.

Dr Haig: The short answer is yes, and that is because, as you know from your constituents, there are a lot of people who have difficulty with the compensation board, and I can assure you that chiropractic patients who have extremity problems have difficulty with the compensation board as well. I would expect that were the legislation to be passed the way it is now, those patients would have increasing difficulty.

Mr Jackson: As a question to the ministry, would it be possible to investigate if the ministry has even looked at the concept of the implications this might have on the WCB and WCB costs? My limited understanding is that the cost would be more extensive. The kinds of therapies and the regular physical checkups that are required from a physician would be more expensive than access to the chiropractors at their rates. Could that be looked into, if in fact the government consulted with this area, in terms of the implications to taxpayers in Ontario, let alone to patients who need this service?

Mr Wessenger: I will refer that to ministry staff.

Ms Bohnen: Remember, please, that the restriction here is not in terms of assessment or treatment of articulation by chiropractors. The issue is confined to statutory authority to diagnose disorders and dysfunctions of these articulations. I think I would then rephrase your question as, will this statutory provision or lack of provision in the Chiropractic Act affect current WCB policy? I do not believe it will, but I would like to take the opportunity to have our staff contact the WCB and get back to you on that.

Dr Haig: Might I suggest that it will have an influence anywhere that there is a third-party payor where there is medical influence, because injured patients, compensation patients, motor vehicle accident patients will be told, "For that injury, you need to see a physician." That is exactly what will happen.

Ms Koch: In fact, I have been actually told by WCB administration that they are watching this very carefully to see that we do have the ability when this legislation is passed to diagnose non-spinal articulations. They are aware of what is happening.

Mr Owens: My question is to the parliamentary assistant. Can you give any kind of rationale why the non-spinal joint diagnosis clause was not included in the controlled acts? I do not understand that they can do just about everything else, receiving training in things like ophthalmology and psychiatry and otolaryngology, but something that is completely germane to their practice would not be included. I do not understand that.

Mr Wessenger: I will refer that to staff.

Ms Bohnen: Fundamentally the review believed that the appropriate scope of practice of chiropractors was in relation to disorders and dysfunctions of the spine and joints, the condition of which related to the spine. I think what we are hearing is a very strongly felt view from the chiropractic profession that their expertise and education qualifies them to diagnose in relation to problems of articulation unrelated to the spine.

I think the issue before the government and the Legislature is whether the legislation should recognize that expanded scope of practice. I am not arguing whether it is expanded vis-à-vis the current law or not; I am just saying the review thought, "Restrict chiropractors' diagnostic authority to the spine and related articulation." They want this legislation amended to authorize them to go beyond that, and that is the issue you have to decide. All I can tell you is that the review thought they were specialists in the diagnosis and treatment of spinal disorders and dysfunctions and that this is where the law should stop.

Mr Jackson: On a point of information, Madam Chair: I am sorry, but the counsel is suggesting that they are looking for an expansion. Are you trying to imply that what my chiropractor did for me was illegal?

Ms Bohnen: No, I am just saying --

Mr Jackson: I just want to make that clear. I understand we are taking away that aspect of it in this legislation and I want to make sure that the record is clear for all members of the committee, including counsel, that this bill represents a restriction in this activity. It does not represent an expansion. I want to make sure we are clear on the language here.

The Chair: It is clear, Mr Jackson, that there seems to be some disagreement on the point you just made. I will ask for final clarification from Mr Wessenger.

Mr Wessenger: It is certainly the opinion of the government that there is no restriction with this existing legislation. In fact, this existing legislation is an expansion --

Mr Jackson: No, that is the Toronto Blizzard.

Mr Beer: Madam Chair, I believe you are going to provide a copy of the Blake, Cassels opinion to the staff. Assuming it is not 500 pages long, could each caucus get a copy?

The Chair: What I would request is that the association give the opinion to the clerk and she will see that all members of the committee receive it. I have one request from Mr Wessenger.

Mr Wessenger: Yes, I would like to have some clarification from counsel.

Ms Bohnen: I think I should have an opportunity to say to Mr Jackson that what I said was that the review recommended restricting chiropractors to diagnosis in relation to spine and spinal articulation. You are hearing a request for an expansion not relative to the existing law -- I do not wish to debate that this morning -- but an expansion relative to what the review recommended.

The Chair: Is that clear for everyone? Mr Hope, you had a request for information.

Mr Hope: Yes, and I am not sure if I will get all this exactly the way it should be, but during the days that the ministry is here, there seems to be a concern, and I guess where the concern lies is with the general public and those people who are victims of work accidents. I feel it would be most appropriate, during a time allocation, if possible, to talk with the board about this whole --

The Chair: You are referring to the Workers' Compensation Board?

Mr Hope: Yes.

The Chair: That is on the dates of September 16 or 17.

Mr Hope: Yes, within that time frame.

The Chair: Your request is duly noted. Mr Wilson, you have another request?

Mr J. Wilson: Yes, a request for information. Perhaps counsel could provide us with the evidence or the reasoning behind the review committee's decision to limit, as we are hearing from testimony today, the scope of practice to diagnose functions.

The Chair: You will have an opportunity to discuss it with Mr Schwartz directly on September 16.

Mr J. Wilson: I am sure there must have been documentation provided to the review committee, and perhaps we could come to our own conclusions, since we are being asked to settle this at this committee.

The Chair: For your information, again I would just state that Mr Schwartz himself will be here on September 16.

Mr J. Wilson: Prior to his arrival I would like to have the opportunity to review how this decision came about, if that is possible.

The Chair: I will just leave that on the record.

I want to thank you for your presentation.

Ms Koch: Thank you, Madam Chair. If I could just take one moment, we realize that time is very tight and we thank you for the opportunity to be able to address some of our very important concerns with you. I want to just note that we have a number of other equally important concerns and we would be happy to discuss them with you any time, anywhere.

The Chair: I would suggest that if you have any additional information during the course of these hearings, you feel free to communicate in writing through the clerk or any member of the committee at any time.

The committee recessed at 1204.


The committee resumed at 1400.


The Chair: The standing committee on social development is now in session. I would like to call on the Ontario Hospital Association and ask that you come forward. You have 20 minutes for your presentation. I would ask that you begin by introducing yourselves, and also, if you would, leave a few minutes at the end of your presentation for questions from committee members. I would ask that you begin your presentation now, please.

Mr Birkness: Thank you for allowing us to make a presentation to you this afternoon. My name is Brian Birkness. I am the chairman of the board of the Ontario Hospital Association. With me is our senior legal counsel, Carolyn Shushelski, who will help me with this presentation. Also with us are Gordon Cunningham, the president of the Ontario Hospital Association, and some of our staff members.

We at the Ontario Hospital Association are pleased today to have the opportunity to share with you our observations and recommendations regarding this legislation, which charts new directions in the field of health. Our association is supportive of the Ministry of Health's and the Legislature's efforts to define and reform the regulatory framework for health care professionals in Ontario. Members of this committee will be aware of our keen interest in the development of this legislation through three governments and nine submissions on the part of OHA since 1982. Committee members have copies of our submission, including an executive summary, and our recommendations regarding the Regulated Health Professions Act and the health professions acts.

This legislation is of vital importance to us not only because of how it impacts on the role of health care professionals but also because of its potential influence on how hospitals will operate in the future. As you personally have observed in the past, this type of legislation will have a ripple effect on other legislative initiatives such as the Public Hospitals Act review. This review is critical to the functioning of health professionals in the hospital. Issues under consideration include who can write orders for treatment and diagnostic procedures, who can admit patients and register outpatients, and which professions will have the right to apply for hospital appointments and privileges.

Another area of concern to us in the proposed new legislation is imposing personal liability on directors of corporations. This will profoundly affect the willingness of directors to serve on hospital boards. OHA cannot support such a provision.

Like many of the organizations involved in health care in Ontario, the OHA believes the safety net clause, the former section 27.04, would, if reintroduced, have far-reaching implications not only for the health care community but for society as a whole. In our view, the potentially negative impact of such a provision would outweigh any existing need for the section. We submitted our comments on this matter several months ago to the Minister of Health. You will find a copy of the letter in appendix A of our submission. We are heartened to see that the Minister of Health agrees with our position and has not included a section similar to 27.04 in the proposed legislation.

Our observations on the legislation and other matters are outlined more fully in our brief, but for the purpose of our discussion today we would like to concentrate on three major areas of concern: delegation of controlled acts, diagnosis and privileges.

Carol Shushelski, the Ontario Hospital Association's senior legal counsel, has made a thorough study of the proposed legislation and will summarize OHA's concerns and observations for the committee.

Ms Shushelski: Members of the committee will understand that we have a special interest in that section of Bill 43 which deals with the delegation of controlled acts. First of all, we are pleased that nothing in this proposed legislation will change the current situation, which permits the board of a hospital to decide which acts, from those permitted to be delegated, will be delegated by one health care professional to another health care professional within that hospital.

We are, however, concerned over how controlled acts are approved for delegation. Requiring the passage of a regulation for the delegation of each act would result in unwarranted delays. Due to the shortage of physicians, in many instances nurses and other health care professionals perform acts in the practice of medicine to ensure the delivery of quality care. This is made possible through the delegation process. It is crucial that determining which acts may be delegated be as simple and responsive as possible. In our view, the delegation of acts should not be the subject of regulation. Instead, it is our recommendation that the established and existing practice of co-operation among the colleges, the Ontario Medical Association and the Ontario Hospital Association continue to be the mechanism by which delegation of controlled acts by or to members of a health care profession is determined.

The proposed legislation must also be amended to accommodate existing realities. One of the problems facing remote areas of Ontario, especially the north, is the shortage of physicians not only to perform the medical acts themselves, but even to delegate them. As part of the delegation process, physicians must teach the act to nurses and other health care professionals, train them, and examine, certify and recertify them on a regular basis. For example, some acts within the practice of medicine are performed by nurses, acts traditionally within the jurisdiction of physicians and requiring a high level of training and skill. Their services are particularly invaluable in those aforementioned areas where the shortage of physicians is acute. We draw this to your attention as consideration should be given to how the new legislation will recognize the role some nurses play in the north.

On that point, I would like to make one comment with respect to the recent addition of authorized acts for nurses. We note that nurses may now perform a "prescribed procedure below the dermis or a mucous membrane on the order of a qualified person." We recognize that this is one way of going beyond the process of delegation; however, I think more consideration needs to be given as to how this would be implemented.

We have serious reservations regarding the diagnosis clause as it is proposed in the Regulated Health Professions Act. Communication by any health care professional to patients is critical to the delivery of high quality health care. Specifically, we are concerned that subsection 26(2) of the act as it is now worded could seriously inhibit communication between health care professionals and their patients.

The section states in part, "Communicating to the individual or his or her personal representative a conclusion identifying a disease, disorder or dysfunction as the cause of symptoms of the individual in circumstances in which is it reasonably foreseeable that the individual or his or her personal representative will rely on the conclusion." We strongly oppose the linking of communication with diagnosis. Communicating with a patient is at the very foundation of effective health care delivery. If the provision remains linked to the diagnosis, health care professionals who do not have the authority to diagnose as an authorized act of their profession may avoid discussion with patients. This includes nurses, physiotherapists, respiratory therapists, pharmacists, chaplains, social workers and others. Fear of violation of the act will cause health care professionals who cannot diagnose to avoid discussing with the patient his or her disease, disorder or dysfunction. As it stands, the utterance of the diagnosis by a person other than the physician or other health care professional authorized to diagnose would be an offence under the act.

With respect to the act of diagnosing, we recommend that the focus be related to the process of diagnosing and not to the utterance of the words. We therefore recommend that the section focus on making a conclusion or identifying a disease rather than on communication to the patient or his or her representative. We are heartened that the minister recognizes the problem and is looking for advice from the committee on wording that will make it possible for practitioners to communicate as fully as is desirable with patients.


Finally, I wish to speak about the legislation's impact on self-employed health care professionals seeking access to hospitals. Existing legislation under the Public Hospitals Act and regulations provides that only physicians and dentists can apply for an appointment to either the medical or dental staff of a hospital. It is also a requirement under existing legislation that all inpatients be admitted on the order of a physician and that all outpatients be registered under the authority of a physician on the medical staff of a hospital. Legislation requires that orders for treatment or diagnostic procedures in a hospital be in writing by the physician or dentist giving the order. Physicians are therefore very much the gatekeepers to hospital care.

There is now a strong body of opinion, both inside and outside the hospital field, that changes should be made to provide other self-employed professions with the opportunity to practise within hospitals. Some of the newly self-governing professions believe they should be able to practise in the hospital setting without necessarily referring patients to or receiving referrals from a physician. Some professional groups, including midwives, have indicated an interest in seeking privileges to practise within hospitals. Some professional groups wish to have access to outpatient care facilities of hospitals and wish to be allowed to write orders for treatment or diagnostic procedures without physician involvement.

On the other side of the issue is the consideration of whether every patient and outpatient should have a physician overseeing his or her care. The outpatient issue is difficult. On one hand, a more flexible approach to access by various health professions to the outpatient clinics and departments should be considered. However, professionals who are not employees go through a stringent appointment process in order to determine what privileges, if any, they may be permitted at the hospital. This includes privileges in respect of admission to hospital and access to and use of outpatient facilities.

Should such a process of credentialling and delineating privileges continue just for dentists or physicians? Should the process be expanded to include other health professions? Should the whole system be relaxed to permit any health professional access to and use of the hospital facilities by virtue of the professional holding himself or herself out as a particular professional?

Any change in existing practices in the hospital setting in respect of patients and outpatients must be given careful consideration in order that all aspects of these issues and questions be fully examined. In that respect, the OHA wishes to make the following points:

The authority to determine who within a profession may be granted an appointment and privileges at a hospital and who may have access to register outpatients should remain with the hospital board.

A hospital board must maintain the right to grant or reject, through its established process, application for appointment and reappointment according to its needs. It must also determine the extent of the privileges within the defined scope of practice of each health professional.

Decisions on whether midwifery service or any other service should be provided in a particular hospital, and how it should be provided, should be made by individual hospital boards based on local considerations.

Within the defined scope of practice of midwifery or any other health profession, each hospital should have the right to establish its own policies, protocols and procedures with respect to the provision of that particular service.

That concludes my presentation on behalf of the Ontario Hospital Association. I will now turn back to Brian for concluding remarks.

Mr Birkness: Members will note that besides the oral presentation, our brief contains a number of recommendations and observations in such important areas as regulation of health care providers, registrars' powers of investigation, quality assurance committee, orders for treatment and diagnostic test.

Members of the Ontario Hospital Association are very aware of our responsibilities to the people of this province in providing the best possible health care. We are also aware that the watchword is teamwork, that everyone charged with the responsibility for health care must work in partnership in order to meet the challenges ahead. We want to assure the members of our continued co-operation. Now we would be happy to answer any questions.

The Chair: Thank you very much for your presentation. All members of the committee have received the full presentation as well as the verbal presentation. I have a question; Mr Beer.

Mr Beer: Thank you for your submission. I know you said with respect to the safety net clause that it is outlined in appendix A of your submission, but I wonder if just for the record, because this is an issue that has come up and I know will come up again, you could summarize the reason you think it is better that clause not be there.

Ms Shushelski: We considered this very carefully at the OHA because we understand that the intention with respect to that clause is to protect the public. We also noted in reviewing the remarks in the original review from 1989 that it was intended that the protection of the public was to be attempted to the extent possible, and we tried to keep that in mind. One of the concerns that we had was that it would in some way inhibit persons who were not regulated professionals from providing care or treatment or advice to friends, family, good Samaritan acts.

Now, we do recognize that the controlled acts have been very well set out, and that there are exceptions and exemptions whereby you can treat someone in an emergency, members of the household. But our concern is that with respect to former section 27.04, it was much broader than the legislation itself was focusing on, and we were not comfortable. We did not feel assured from the way it was worded that it would not inhibit persons from coming forward to help others; a mother, for example, applying a Band-Aid, perhaps a hot-water bottle, things that it may never have been the intention of the legislation to inhibit. A volunteer, someone in the community, who wanted to help someone, care for them and advise them -- would they feel somehow inhibited, would they feel stifled? We felt that if that clause were to be introduced, and in our brief, we make the point in some detail, there would have to be recognition that individuals in the community would care, treat, advise, and the degree to which persons would be able to do that would have to identified for those particular categories of individuals.

Mr Owens: One of the issues that has been flagged in front of the committee, especially by nursing groups and nurses themselves, is the issue around standing orders. As an employer representative, have you ever been in a situation to advise an employer when a physician has refused to sign retroactively a standing order where a nurse has taken action to perform a procedure? What advice would you give an employer in that situation?

Ms Shushelski: The first question, have I ever been asked? I am not aware of a physician ever refusing to sign an order for which he set up originally. What happens with standing orders is -- and you are probably aware -- that the hospital, as well as the physician, all the parties involved, are very clear about what will be a standing order.

What I advise is whenever you have a standing order, and this is the advice I give, even before you go ahead with the standing orders -- you know what they are; they are written in front of you -- is that a confirmation is necessary over the telephone, whatever, if possible with the physician so that you are confirming it, and then he or she signs the order upon arrival at the hospital thereafter.

As far as a physician refusing to sign an order for which he has already set up, I have just never experienced that happening. But certainly, if the nurse did not follow the standing order as it is set out, then I think the physician has a right to question why he should sign an order that someone has not followed appropriately.

Mr Owens: There seemed to be an issue around the physician second-guessing the nurse in terms of whether the procedure was, at the time, warranted. In the nurse's judgement, it was, and the physician apparently felt that it was not. So this is the issue that has been flagged in front of the committee.

Ms Shushelski: My understanding of a standing order is that these are already written out very clearly as to what happens in this particular situation. I am not clear as to how the physician would be second-guessing the situation. If the patient is arriving and is going to the operating room for an appendectomy the next day, it is quite clear what has to happen. The orders are generally set up that you do certain blood work, urinalysis. It is quite clear.

Mr Owens: Maybe in terms of saving the committee time we should get together with the Ontario Nurses' Association and talk about some of the issues they have had with respect to problems without standing orders.

The Chair: I have mentioned to other groups and organizations such as yourself who have brought forward excellent presentations that if there is any additional information based on some of the questions -- I know you will be monitoring the proceedings through Hansard -- if at any time you feel there is information that the committee should have which would be helpful, please feel free to communicate with us in writing through the clerk.



The Chair: I would like to call now on REAL Women of Canada. Please come forward. I would ask that you begin your presentation by introducing yourselves and ask if you would leave a few minutes at the end of your presentation for questions from committee members.

Ms McNamara: My name is Lorraine McNamara. I am a legal secretary and a mother of six. Mary Fay here wears a lot of hats, but she is a registered nurse. I am not sure if you have a family too, Mary.

Ms Fay: No, I am not married.

Ms McNamara: Not married? Well. Mary and I are REAL Women, but we have just met for the first time this minute. As evidenced by our presentation to the Task Force on the Implementation of Midwifery in Ontario in October 1986, and I have attached a copy to this presentation, REAL Women of Canada has serious concerns with respect to the training, responsibilities and rights of midwives in Ontario.

We have no quarrel with the intent that midwifery be given professional status. The occupation of midwifery is respected worldwide. We welcome the establishment of an official College of Midwifery. However, recent tragic events in which apparently unqualified midwives acted in both BC and Ontario resulted in the death of babies. That does point up very strongly the need for some kind of control.

However, the College of Midwifery, which is to be a regulatory body coming into existence under Bill 56 at the same time as passage of Bill 43, we understand, is to be self-regulating. The final decision has not yet been made with respect to prerequisites for membership in the college, although apparently the Interim Regulating Council on Midwifery has decided that a nursing diploma will not be necessary. It is expected that some form of post-secondary school education, possibly university-level, will be required and entry may be direct into the college. There is at this point no midwifery training program in existence. This has not been decided yet.

The objection of REAL Women to the passage of Bill 43 with respect to midwifery is simply that there is no track record on which to base the right of self-regulation for the proposed College of Midwifery. By track record we mean there is not a sufficient history of midwifery in Canada to provide the necessary knowledge and hands-on experience to justify setting up a college independent of the established medical professions.

REAL Women believe in the future of midwifery in Ontario. For example our national president, Judy Anderson, told me she was delighted to have the assistance of a midwife before her last baby, and the midwife was at the hospital with her for the birth and gave a lot of helpful assistance following the birth.

I was not going to mention this, but I might tell a little anecdote which is personal. My last baby, number six, was born in hospital, and while I was waiting in the labour room the nurses approached and they said: "You seem a fairly relaxed mother. Would you let us test this new monitoring equipment we have? The salesman is here and he's trying to show us how it works." So they had me belted up and they had the machinery there and all the little blips going and the poor salesman was having a dreadful time demonstrating. Finally one of the nurses looked at me and she just looked at my face and finally she said, "Whoops, the baby's here," and that was it, out of the room for everybody, the baby was here. She was a nurse-midwife. She delivered the baby. It was the nicest delivery I have ever had. She was super. So my personal experience with midwives is very, very positive.

A review of the other professions which would be granted self-regulatory powers under Bill 43 indicates that most of them have long-established colleges or associations which have over the years developed strict accreditation requirements. For example, a dietitian must complete a four-year bachelor of science program and serve a one-year internship; a physiotherapist must complete a bachelor of science program plus further qualifying training; a chiropractor must obtain a bachelor of science degree with high standing plus three years at chiropractic college and a one-year internship.

It has not yet been decided exactly what prerequisites would be required for midwifery except that, unlike the British system, a nursing diploma will not be required. I would mention here too that midwives will be authorized to perform and repair episiotomies, give injections and employ invasive procedures. All of these are medical procedures. We pose a question: Had professions such as chiropractic or dietetic requested self-regulatory powers before their associations had established credible records, would these powers have been granted? Probably not, yet neither chiropractors nor dietitians are likely to encounter the sudden life-and-death situations which inevitably will be faced by some midwives.

It is understandable that no profession would willingly suffer negative publicity or even the possibility of a lawsuit, which could happen if one of their members is found to be incompetent. There is a strong temptation for these people to cover up situations like that, and just recently the doctors have been seriously criticized because they were not dealing with complaints about sexual abuse of patients. It has been felt that they were not dealing with it properly.

A recent task force headed by lawyer Mary Lou McPhedran made several startling recommendations, one of them that the complaints and discipline committee of the College of Physicians and Surgeons be loaded with members of the public. That would result, in certain instances, in the college being put under the control of non-medical people and that would mean they were not self-regulatory in that instance. If the right of self-regulation by a highly respected profession in matters dealing with sexual abuse of patients can be challenged, surely this committee should question the self-regulation of a not-yet-established college, some of whose members may very well face life-and-death situations.

The proposed College of Midwives would indeed be self-regulating. The council is to be composed of up to 10 elected midwifery college members and up to only five government appointees. This council will in turn appoint members to the following committees -- I will not go through the makeup of them -- executive, registration, complaints, discipline, fitness to practise and quality assurance. In all of these, if you have noticed from our presentation here, the ratio is very much in favour of the college members, so they would be self-regulatory.

It should be noted that nowhere in Bill 56 is it indicated that medical backgrounds would be required for council members. Especially with respect to the council members who are to be appointed by the government, it leaves the door open for the appointment of political activists who may not be at all competent in medical matters.

In Canadian law today, while the mother is protected against bodily harm, there is no protection for the unborn child. Until a baby is free of the birth canal and breathing, he or she has no status as a person under Canada's criminal law. The recent Sullivan and Lemay case, in which two midwives were found to have been at fault in the death of a baby whose head was free of the birth canal but who was not yet breathing is a frightening example of this fact. This situation is not unique. There was a similar tragedy recently in Ontario.

Because there is no law protecting the life of an unborn child, this Legislature must make every effort to ensure the safety of its littlest citizens. It follows therefore that the profession of midwifery must be competently controlled and scrutinized.

REAL Women of Canada respect the profession of midwifery and agree that a College of Midwifery should be instituted in the province of Ontario. However, since there is no existing midwifery organization in Ontario which has proved over the years that its members are well trained and competent, we do not believe the proposed College of Midwifery should become self-regulating upon its inception. We suggest instead that until such time as graduates of the College of Midwifery have been in practice long enough to assess their capability as midwives, supervision of the college should be placed with experienced medical organizations such as the Ontario Nurses' Association or the College of Physicians and Surgeons of Ontario.


The Chair: Thank you very much for your presentation.

Mr J. Wilson: I too want to thank you. What do we do with the midwives who are currently practising, though?

Ms McNamara: There were probably recommendations made by the interim committee that has been studying it. If one of the recommendations was that they would, say, have to have a university degree, that might be a problem right there. I do not know how they were solving it. I would say that they would need training. Again, I would like to see the training come under the medical establishment.

In Ontario there is really no excuse for not getting at least a nursing degree if you are going into midwifery. Nobody is denied an education here. It is not like many parts of the world where this is the only thing available. If a person cannot handle a basic nursing degree, the first level, then I would question the competency of the midwife. I do not think, by the passage of this act, that it is going to make it illegal. Is it? That I do not know, but the same problem would arise even with the establishment as it is set up here. A lot of those who are practising probably would not qualify.

Mr J. Wilson: Perhaps the parliamentary assistant would like to comment on the suggestion here that we hold off establishing a college, because I think there is more to this.

The Chair: Mr Wessenger, would you like to comment?

Mr Wessenger: I will turn that over to staff.

Ms Bohnen: The recommendations of the task force on the implementation of midwifery clearly recommended that midwifery be a self-regulating profession. The same criteria which were used by the Health Professions Legislation Review to consider whether other health professions should be self-regulating were applied to midwifery. The criteria were satisfied. We do have practising midwives. Ontario will be establishing an educational program for midwives, as well as an integration program for existing practitioners. I do not believe this government or the previous government could consider other than the proposals that you see before you.

The Chair: Question, Mr Owens.

Mr Owens: My question is of two parts and the first is to the parliamentary assistant. My understanding is that one of the recommendations of the Interim Regulatory Council on Midwifery is to establish the baccalaureate as the entry to practise, with a time period set up to bring people up to speed. Is that not true? Is that not what we heard this morning?

Ms Bohnen: There are going to be two programs. There will be a basic four-year educational program for people who do not have previous qualifications or experience in midwifery or a related health science, so it will be for high school graduates choosing a university program. In addition to that there will be a pre-registration or integration program for currently practising midwives who have experience and qualifications in midwifery but need to be examined to ensure that they are competent to provide safe and effective midwifery care.

Mr J. Wilson: Just a quick comment. One of the intentions of the legislation is to open up the practice of medicine specifically to women who up to this point have been relegated to second-class status in the health care professions. The question I have is that you make a comment about midwifery not having a track record on which to base self-regulation. I would propose that midwifery has been around for a lot longer than many of us sitting in this room and I am not sure where you draw the basis to make that statement.

Ms McNamara: As an association; I have no problem with midwifery. I agree, but at this point to actually make it a self-regulating organization, without even having the college functioning for a period of time to prove that they are doing a good job, I just do not think is sensible. I do not have a problem with midwifery. Mind you, I do not think you take it as lightly as all that. The births of my children have been relatively easy, but a lot of people have problems and I think it is a fairly serious thing. There is always the crisis situation, and whoever is the midwife has to be ready for that.

Mr J. Wilson: I would further suggest that the medical establishment that you feel should do the training -- I think a lot of women have had problems with the attitudes and the activities that are going on. Just recently the College of Physicians and Surgeons of Ontario and its task force on sexual abuse have proved that there are difficulties within that establishment, and maybe it is time to move out.

Ms McNamara: I have a little more confidence in our medical establishment than that and I believe there can be a coming together of the midwives and the medical establishment to establish standards. I am not saying they will not be self-regulating eventually; maybe down the road. I just want them to establish themselves first for a reasonable period of time and have everything set up and then ask for self-regulation, just not right now. I do not think any organization which is not even in effect yet should be self-regulatory right off the bat. I should not say "I"; we do not feel that way, and we are just trying to protect women, really. We think this is a reasonable and a sensible approach to take and I cannot see why these two groups cannot get together. It almost sounds as if the physicians are on this side and the women are on that side, and that is not the case -- maybe a few.

The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee today. As I have mentioned to other deputants, if at any time you feel there is additional information you would like the committee to have, please feel free to communicate with us in writing. Thank you very much.


The Chair: I would like to call Steve Goring. Please come forward. Welcome to the standing committee on social development. You have 10 minutes for your presentation. The committee has received your written presentation -- we are receiving it even as we speak. Please begin now.

Mr Goring: Hello, my name is Steven Goring. I am pleased to be invited to present my views to you today. I am not here representing any organization; rather I am here to talk to you as a consumer of psychotherapy. Specifically, my concern is around the assessment or diagnosis clause which, if this morning is any indication, you have already heard a lot about.

I have misgivings that if the legislation as it presently stands becomes law, the way psychotherapy is practised by most practitioners will become illegal. In order for me to be clear about my misgivings, let me first talk about two things: the psychotherapy session and how psychotherapy works.

A typical session with my psychotherapist starts off with me talking about things that are occurring in my life. My therapist is meanwhile taking in information, empathizing with my emotions and looking for areas that I seem not to be aware of or that I skip over. This may lead to questions and, in turn, a dialogue in which there is an exchange of information and viewpoints. It is this exchange that I fear is threatened.

How necessary is this exchange to bring about a positive outcome in psychotherapy? Something many schools of psychological thought would agree on is that the way we view any given situation is coloured by our preconceptions of how the world works. In my experience, the exchange of viewpoints allows me to see a situation through the perspective of another. It is within the context of a strong, supportive client-therapist relationship that I can undergo this sometimes emotionally painful shift in perspective that is the core of how therapy works. My therapist's assessment of a situation is often the catalyst to this transformation.

In order to illustrate how this could be legal, I have a couple of admittedly simplistic examples I want to share. Let's say that recently I have been suffering from insomnia. I tell my therapist I have been tossing and turning without being able to get a good night's sleep and that in the morning I wake up exhausted and stiff all over. I attribute this to my uncomfortable bed and express my intent to buy a new bed in order to get a better night's sleep. Later in the session, while talking about how the spark has gone out of my life since the relationship I was involved in ended, my therapist ventures her assessment, which is that the insomnia, which can be labelled as a symptom, is caused by my depression, which could be thought of as a disorder, following the recent termination of the relationship. I rely on her conclusion and decide not to go out and buy a new bed. This example is in some ways almost comical and my therapist could cover herself by sensibly recommending that I also seek the advice of the doctor. But my point is that in giving her assessment, knowing that I might rely on it, she has contravened the law.

Let me give another example. I complain of feeling anxious and assume that this is part of my constitutional makeup. After exploring the issue with her, my therapist mentions her assessment, which is that my present anxiety -- here, think "symptom" -- is caused by a strong jealousy, which could be thought of as a dysfunction, around my girlfriend's starting a new job in which she has to deal with a lot of men. Relying on the therapist's conclusion, I decide to stay in therapy and try to resolve my jealousy. Again, I want to draw your attention to how my therapist has communicated a conclusion identifying a disorder or dysfunction as a cause of symptoms, knowing that I may rely on the conclusion.


I understand that the government is not interested in putting psychotherapists, who are not MDs, psychiatrists or psychologists, out of business. I realize that the intent of the law is the needed and admirable goal of public protection and accountability. I think it can be justifiably argued that the government is not going to go around prosecuting psychotherapists who are properly practising. However, my concern is with the possibility that some psychotherapy client who is enraged with his therapist over some breach of empathy would sue his therapist for malpractice. If this clause is passed as it stands, I suspect it will leave psychotherapists, as well as other professionals, vulnerable because of the ambiguity in whom and what it is aiming at.

I think consumers have a lot to lose if the reality of the therapist's vulnerability is brought home to the psychotherapeutic community through a lawsuit by some disgruntled client. Certainly I could see it having the effect of fewer people being willing to enter or even remain in the profession. This would mean less choice and greater difficulty for the consumer in finding a psychotherapist.

Consumers will also lose if psychotherapists become more selective about whom they work with, screening out those who might be too difficult or risky to work with.

Finally, having a therapist hobbled by worrying about whether he is breaking the law each time he speaks is not conducive to the client's getting his money's worth from the therapy. I am concerned that even the thought of this legislation passing as it stands has a number of therapists I know worrying about their ability to continue practising. As a consumer, I want to acknowledge the invaluable service that I have received from my time in therapy and I hope future consumers will have as much access to good psychotherapy as I have had.

Thank you for your time, and I will be pleased to try to answer any questions.

The Chair: Thank you very much for your presentation. We appreciate your appearing before the standing committee on social development today.

Mr Martin: I also want to say thank you for coming. It is nice to hear from a consumer of health services in our province and to hear of your concerns around this whole question of regulating those who deliver the service.

You confirm a couple of things for me; one, that certainly the consumer is not perhaps as confused or ignorant of the system that is in place as we assume, and that in fact we may be doing something sometimes in terms of setting up regulations that speak to a fear of those who would misuse, rather than an excitement about the possibilities if we allow those who practise in good faith actually to do the job. I sense from you that to do what we are doing regarding the diagnosis clause that we have here would in fact bring more confusion rather than less confusion. Is that correct?

Mr Goring: Yes. I think that any confusion it brings within the community of psychotherapists not covered by the diagnosis clause would affect the consumer. I really support the thrust of this legislation, to try to get the charlatans who are out there, but they get a lot of press and I thought it was important to present the other side too, which is that this legislation might catch a lot of good people out there who are doing good work.

The Chair: Thank you very much. We appreciate your appearing before us today.


The Chair: Is Jane Chamberlin here? Please come forward. You have 10 minutes for your presentation. We ask if you would leave a few minutes for questions from the committee. Please be seated, and welcome to the standing committee on social development.

Ms Chamberlin: I am pleased to have the opportunity to appear today. I am present as a private individual, but one who has served as an appointed member to the Ontario College of Pharmacists for nearly six years, so I will speak mainly to the issues of the effectiveness of public members on the college councils.

I strongly support increasing the numbers of public representatives on the colleges. I would say, however, that the effectiveness of the public members is limited not only by their small numbers but by their personal skills. A professional representative, by virtue of his professional expertise alone, has something to contribute to the work of the college. Only with intelligence, strong views and the confidence to express those views will an appointed member be prepared to contribute meaningfully. If the Legislature increases public representation to just under half, without the ability -- and I suggest that is currently the case -- to recruit capable individuals, it runs the risk of creating large, unwieldy governing councils to no purpose.

I wholeheartedly commend the current government for increased attention to the qualifications of proposed appointees. A very high level of competence among appointees will be required to provide a net benefit to the colleges and to the public they serve if their representation is to be so markedly increased.

In sum, I would recommend that the numbers of public appointees be increased beyond the levels proposed only if there is a strong commitment to ensuring their competence through the selection process and through effective orientation and continuing training programs.

I would suggest a couple of possibilities for widening the possible scope of the talent pool for public representatives.

First of all, as it stands, I think appointments are currently limited to the rich, the leisured and those who are willing to make personal sacrifices to serve because of the demands on time and the low remuneration. I would suggest that in order to increase the likelihood of an employer allowing an employee to serve, and therefore getting representation from all those who are employed -- obviously, a vast majority of adults -- employers should receive a tax credit or charitable donation receipt to compensate for lost employee time. These enhanced benefits should also be extended to the individuals who serve, if the government feels unable to increase the levels of the honoraria.

Members of the public service of Ontario are excluded from service, and while I understand the principle of that, I wonder if it has not been extended a little too broadly. Clearly, those who work for the Ministry of Health must be excluded, but it would be, one would think, relatively easy to persuade other public service employers that there was a benefit to having their employees serve.

Committee representation: I feel very strongly about this. I think that this is one of the ways you can make the biggest difference to the effectiveness of public members, and that is, if you are increasing the number of public representatives on the councils of colleges as a whole, it makes no sense not to increase the representation on committees, where the bulk of the work is done. It would only be as a member of college council that you would recognize that this serves to isolate public members. We never see how the other public members function except at meetings of the committee or the council -- I mean those two terms interchangeably -- so if an issue strikes you as perhaps having a particular public interest benefit or slant, it is often very late on before you pick up on that and you have no one who comes from that similar background to talk about as those issues are in committee.

I would suggest that if you increase total representation to just under half, you mandate two public members on each statutory committee, and that if you increase it to the point that it is now in the legislation, you mandate an increased representation on the executive committee, and I would be delighted to talk to anybody about that further.


The terms of service: I think you will all recognize that on the college councils there is a tendency to think of there being two classes of members. That serves no one's purpose. Once you are there, your job is the same, your task is the same. You come from a different background, but you have the same purpose. So continuing distinctions among those members only serves to continue to distinguish between two classes of members. I would suggest there is a strong benefit on the limitation of term, and I would suggest that this benefit extends equally to professional representatives and public representatives.

Finally, and I will read this verbatim, it is very difficult for any group, even a group of professionals, to understand that they are to elect a representative who will not represent their issues. You all are imbued with the notion of an elected representative representing the issues of the people who vote for them. That is not the case on these colleges. They are sometimes there to act directly in contravention if the public interest contravenes the professional interest of the members, which it does not often do but which it occasionally does. It is very hard for those professional people to understand fully and to support fully the role of the colleges.

Current election practice at the Ontario College of Pharmacists is two-year terms. This makes the members very sensitive to the fact that they have to be re-elected when they are dealing with dicey issues.

There has been a very recent clear example of such a dicey issue. At the moment, this has meant that current members of the college council who voted, in the public interest, to remove the sale of tobacco from pharmacies have done so under the watchful eye of an electorate. At least four members who voted in favour of that move have now lost their seats and have been replaced with individuals whom the pharmacists feel will better represent their own interests. This is unfortunate, inappropriate and decreases the likelihood of effective self-government. You will note that it is not the council members who failed to act in the public interest on this case, it is the electorate.

I would suggest that, assuming it is necessary to have an elected rather than an appointed council, the colleges should be strongly encouraged to extend the term of office to three years -- I understand this is not directly before you today and it is an indirect responsibility on your part -- and that once elected, a member who has fulfilled the rule requirements should be eligible for a one-term reappointment by the council itself.

Additionally, colleges should be encouraged to develop strong orientation programs for both professional and public members to ensure that they are fully aware of their role and of the seriousness with which the colleges attend to the duty to act in the public interest. I solidly expect that the College of Pharmacists will be actively engaged in developing a very strong orientation program under the current circumstances.

Since my term ends in October, I will shortly be a retired public member. I would welcome the opportunity to assist or advise any group which has responsibility for increasing the effectiveness of public members on the councils of colleges of the regulated health professions. I thank you for the opportunity to be here today and welcome your questions if you have any.

The Chair: Thank you very much for your excellent presentation.

Mr J. Wilson: Just a quick question. Are you envisaging then that the College of Pharmacists will have difficulty perhaps attracting people to fill the nine slots that will be filled by the Lieutenant Governor in Council?

Ms Chamberlin: I would suggest that the appointment process at the moment indicates, from the view of the receiving body, that there has been limited success in attracting the kinds of people who are fully capable of actively participating in the affairs of the college. While I support in principle the opportunities that would come from increasing public representation, if you have only warm bodies in chairs, you are making a heavy, less functional body to no aim.

Mr J. Wilson: I appreciate the frankness of your presentation, because it seemed to me from the beginning that the decision to increase the lay members of councils was indeed a political decision. Having been a former assistant to the Minister of National Health and Welfare, I tell the government -- and I have mentioned it before -- it is darn difficult to find the hundreds of people you require for these councils, with the enormous turnover, very often.

Having said that, the purpose, of course, is to try to give better representation and balance to the public. I certainly appreciate your comments and welcome your research.

Ms Chamberlin: The interests of social justice aside, and the interests of the effectiveness of the body being my motivation, I would suggest that representation can be achieved, but it should not be achieved at the expense of effectiveness. You can encourage effectiveness by continued training of professional and public representatives in their role. You are going to have huge numbers to find when this legislation goes through.

Mr J. Wilson: I absolutely agree. Is there any training in place?

Ms Chamberlin: Yes, there is. The ministry, since the days of Murray Elston, has initiated a two-day workshop for public members. It is good, it is well intentioned. It is not adequate, and it certainly will not be adequate with the multiple new members.

Aside from the training, you need to be able to draw from a better pool. You have retired people, homemakers, wealthy people and people who are dedicated to public service who are willing to sit on these bodies and who have the combination of time, skills and understanding of the processes. You have to have a gutsy person in the chair to get up and running quickly and feel capable of dealing with professional issues. There are lots of people who never make it to that level of confidence that they can essentially argue or that their view is as valid as the professional members' view in a self-governing body. You need more bodies to do that; that will help, but you need more capable bodies too.

The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee today.



The Chair: I would like to call Norma McLaughlin. Welcome to the standing committee on social development. You have 10 minutes for your presentation. I would ask you to address the committee now and leave some time for questions, if you would.

Ms McLaughlin: I appreciate this opportunity to make a presentation regarding the diagnosis clause.

My presentation is based on candida albicans, from which I suffer, along with thousands of other people, and the kind of help and care I received from the medical profession and alternative care people.

What is candida? It is yeast. We all have yeast in our bodies, the good and the bad yeast. If the bad yeast overcomes the good, an imbalance results in yeast overgrowth. It becomes a fungus and is called candida albicans.

You often hear Epstein-Barr virus -- chronic fatigue -- or myalgic encephalomyelitis, or ME -- it is better for me to say ME; I cannot pronounce that word -- mentioned along with candida. Herpes zoster virus, which is shingles, enters our bodies via chicken pox. Later on in life, we sometimes break out in shingles from the virus when our immune system is low, which means we have a candida problem. You can have a problem long before you get full-blown candida albicans like I have, and most of the time you do not know you have it. Herpes EB and herpes mononucleosis are activated by the candida. ME is supposed to be worse than Epstein-Barr virus. I do not know for sure, because I have never seen anything in print, and I think EB is much worse than mononucleosis. I have slight bouts of herpes zoster -- shingles -- and brain damage caused by the toxins from candida, which makes it difficult for me to write. I have a constant upset stomach, which is very common to people with a candida condition, severe constipation and athlete's foot.

I became aware of failing health in 1989 with the following symptoms: Frequent and urgent urination, acid stomach, feeling of lethargy and loss of appetite. Also, I was not too constipated at that time. I was starting to have trouble and could not quite understand why. I realize now that it was a candida problem.

I consulted my own physician. He ordered an ultrasound, which showed a small hernia. That was not much help. Then another doctor in town ordered a barium enema. I did not bother with it because I did not think it would help.

Anti-aging program: I heard about a doctor conducting an anti-aging program in Toronto. I decided to try that. He tested my urine, stool, blood and everything and put me on the program. I was on it for some time and did not seem to be getting any better. I developed athlete's foot and he knew I had candida. Blood tests, etc, were ordered again.

He prescribed an antifungus drug, Nystatin, and a diet of water and vegetables. I could not eliminate the debris caused by the antifungus drug when it killed the yeast, and I became severely constipated. I called the doctor in Toronto and he advised colon irrigations, of which I had several, but did not feel much better.

As soon as I found out I had candida, I told my own doctor on the advice of the Toronto doctor. My doctor said to me, "That is a lot of horse manure, this candida thing." A lot of doctors do not believe there is such a disease. He prescribed stool softeners, which were not any help at all. It is written in this book that I mention here, The Silent Killer, that you have to be very careful when you are prescribed this antifungus drug. A lot of things can go wrong and some tragedies happened. This book was written in 1988. The medical profession, both psychiatrists and medical doctors, issued statements to the press that it was all in our heads.

This caused a lot of hardship for some people because their families and friends turned against them. They did not believe there was such a disease, because we were half-sick and half-well, the walking sick. Some of us were able to get around; others were unable to walk very much, suffering from Epstein-Barr, which attacks the muscles. Some people seem to have Epstein-Barr with candida secondary, which is the worst. I am the other way around.

The chiropractor, homeopath, acupuncturist -- that is one person. Also, I was advised from another patient suffering from candida to see this care giver because he helped her. He had a good knowledge of candida, was very understanding and helpful with his advice.

His tests on a computer showed that none of my systems were working -- digestive, kidney, etc. He gave me laser acupuncture treatments for all systems and I improved, put on a little weight and was able to eat. I still need a further treatment. He only does one thing, so I sought the treatment of a naturopath. He gave me a computer test of the whole body, and the printout showed the debris was lodged in my colon, especially in the ileum. He believed in building the body to fight the disease and did help a little, but he was not candida conscious and did not know how to remove the debris. He did do a lot of good for my kidneys. He reduced my acid from 300% to 100%.

Iridologist: I went to her because I thought she would test me for allergies. She confirmed there was debris in the right colon and wanted to administer some herbs and put me on a fast, but I declined because I did not think she was the person to do this.

Another naturopath: Thinking it would help, I tried to find someone who knew about hydrotherapy, which is water treatment. I had read about this in different magazines, in different literature, but she did not know much about it, except to use hot and cold compresses. She advised me to eat as many green, steamed vegetables as possible to go through my intestines. My bowels moved, but I still was not satisfied and did not feel well.

In the spring, I drank a mouthful of hydrochloric acid by mistake. I was rushed to hospital, where they gave me first aid, ran an IV and also took an ultrasound. The doctor who did the ultrasound reported to my doctor that there was an awful lot of stuff in the right colon. My doctor also noted that my stomach was hard, but did not know what to do other than prescribe some suppositories. They were no use at all.

Colon irrigation: I phoned around and found an RN who does colonics. I called her and told her how badly I was impacted. She told me she had a lot of experience and could help. She found that my transverse colon was all impacted, which probably accounted for my stomach being hard. I have had a month of treatments, colon irrigations. She has made a study of my case. She ordered hot castor oil compresses three nights a week for an hour and a half, followed by some olive oil to drink on the fourth day, and drinking lots of water. She has been successful in removing quite a bit. It should take possibly another three months to get it all out.

Between her and the acupuncturist, I feel I am getting good care, along with the knowledge I have gained from studying my own case, but I should have a stool, blood and urine test. At an appointment with my doctor, he took my blood pressure, weighed me, did not listen to a word I had to say about my colon, and stood up for me to leave. In a few minutes, I was outside his office and had not told him about these tests.

This is my story. We have an association in Collingwood of these people. There is also one in Orangeville, Orillia and Owen Sound, probably in every town if you went to it, lots of them in the city. There is story after story of doctors rejecting them when they cannot diagnose this candida, which also leads to Epstein-Barr. Some are worse off because they do not study their own cases or consult other care givers. Some are prescribed tranquillizers by doctors, which is the very wrong thing to do.

I found that in different books. This book, Candida Yeast Infection: The Silent Killer, by Rupert Bebee of the Healthology Association of Canada, has input by several doctors. I got a lot of information by it. He thinks alternative care and the medical profession should work together. Both are needed.

The last paragraph is my own comment and is not from the book. The medical profession has come out badly on this disease. They feel confronted. It is a complicated disease and they do not want to get involved. Each patient should study their own case and be equally responsible. Each is different because we are all different with different biochemistry and different constitutions. I have studied three books by medical doctors, three books by naturopaths, and use the knowledge from both.

I am satisfied with my alternative care givers, but I also need a medical doctor. Finances have been very stretched for me. I have paid all my own way to go to the other care givers and I have had to rent rooms and do other things to get by. There is one thing that both these doctors can do who found my colon is impacted, and that is give me a colostomy.

The Chair: Thank you very much for your presentation. The committee appreciates you coming before them today and bringing us your perspective, and we want to thank you very much. If there is any additional information you think would be helpful to the committee, please feel free to communicate with us in writing. Thank you very much.



The Chair: I would like to call now the Board of Directors of Drugless Therapy and Naturopathy. Please come forward and begin by introducing yourselves. You have 20 minutes for your presentation. The committee has received your written brief; please start your presentation now.

Mr Spring: My name is Jim Spring and I am the chairman of the Board of Directors of Drugless Therapy and Naturopathy, the regulatory board for the naturopathic profession in Ontario. My colleague, Rod Gratis, is the vice-chair of the board, and will be presenting with me. Thank you for the opportunity to address you today. Our presentation will be informative, very brief and to the point.

Mr Gratis: Naturopathic medicine has been continuously regulated in Ontario since 1925. In that time, there have been well over an estimated five million patient visits to naturopaths by the residents of Ontario, and from all of them there has never been a reported serious injury or death as a result of those treatments. In other jurisdictions, untrained persons claiming to be naturopaths have caused serious injury and even death.

This enviable record is purely and simply the result of competent and responsible self-regulation of professionals who practise what they were trained to do. Regulation is absolutely necessary to protect the public.

The standards for entering the profession include university pre-medical training, a minimum of three years, followed by four years of dedicated, full-time, naturopathic education and, upon graduation, passing the rigorous board examinations. That is a total of seven years post-secondary training as the minimum, and most of us have more. These requirements have done an excellent job of protecting the citizens of Ontario as they receive safe and effective naturopathic treatment.

As the board scrutinizes and regulates its practitioners, it also constantly strives to further improve the ways it can protect the public.

For your reference, the traditional scope of practice of naturopathic medicine includes botanical medicine, clinical nutrition -- which is much more than the four basic food groups; it includes the actual relationship between nutrition and disease -- diagnosis, oriental medicine and acupuncture, homeopathy, manipulation and some physical modalities, all done safely and effectively for over 60 years of regulation in Ontario.

The Board of Directors of Drugless Therapy and Naturopathy does not live in a vacuum. We communicate regularly with other licensing jurisdictions and organizations in Canada and elsewhere. We stay abreast of the constantly changing technology and research showing the safest and most efficacious methods for procedures and treatments to be accomplished and make certain that Ontarians receive the benefit of those.

Interestingly, other jurisdictions that maintain the effective principles of self-regulation of naturopathic medicine, as practised here, also have excellent records of public protection.

In closing, the naturopathy regulatory board urges you to retain effective regulation for naturopathic medicine, making certain that the traditional scope of practice, which is demonstrated safe and effective both here and elsewhere, be retained and regulated in its entirety.

Thank you, Madam Chair. We have left lots of time for questions.

The Chair: Excellent presentation. Questions from committee members? Thank you very much for your presentation. I know the folks following you are the Ontario Naturopathic Association. Perhaps they will join you now and then if there are additional questions that are raised, they can be answered.


The Chair: The Ontario Naturopathic Association, please some forward. You have 20 minutes for your presentation. Please begin now.

Ms Wales: My name is Pat Wales. I am a naturopath and I am the immediate past president of the Ontario Naturopathic Association. With me here today is Dan Labriola. He is also a naturopath and is the director of government affairs for the association.

The Ontario Naturopathic Association represents naturopathic practitioners in Ontario. Our mandate is to maintain the safe, effective and complete practice of naturopathic medicine in Ontario. At the back of your handout there is a green brochure. This brochure outlines the practice in Ontario. I will not go into the details, as we have just heard about those from the regulatory board. I will quickly review, however, a little of the history that has led us to where we are now, after which Dan will outline our specific concerns for the future. We want to be brief and to the point.

In 1986 the HPLR and Health Minister Elston felt that the naturopathic profession had not adequately met the criterion for "body of knowledge." This was one of the nine criteria the HPLR had set for self-regulation of professions. This particular criterion is considered especially important, for without it a profession is not considered capable of disciplining errant members and thus protecting the public from harm.

Following Minister Elston's announcement, the naturopathic profession proceeded to provide new information to the ministry about "body of knowledge," and more. As a result of the new information and a careful review of all the facts by then-Minister Caplan, it was decided to continue the regulation of naturopathic medicine. But since the advancement of the act by this time was on the fast track and ministry officials felt there was not time for our profession to be included in the new law, it was decided that we would be the first profession to apply to the new advisory council after enactment, and in the meantime we would remain continuously regulated under the Drugless Practitioners Act.

As the regulatory board before us has stated, our history for self-regulation and protection of the public interest has been excellent, and we aim for it to be even better in the future. Ever-increasing new outcome studies for botanical medicine, clinical nutrition, manipulation and the other modalities we use are enabling doctors of naturopathy in Ontario to provide even better treatments for the 300,000-plus patient visits we see each year.

It is of interest to note that the only college training naturopathic practitioners in Canada is located here in Toronto, in Etobicoke. The Ontario College of Naturopathic Medicine is one of only three in North America, and we are very privileged to have it here in Ontario. The entrance requirements include three years of university pre-medical training. The four-year full-time program includes clinical training under the supervision of regulated naturopathic professionals.

I would now like to ask Dan to describe our specific concerns for the future.

Mr Labriola: Bill 43 is certainly a quantum leap forward in the omnibus health care legislation and pioneers new methods and new processes for managing health care professions. I think it is safe to say that Ontario is not only leading the country but perhaps leading the world in this kind of regulation. But as with all new and noble ventures, which this certainly is, I think we need to be certain we do not add any ingredients that cause this legislation to do something other than protect the public interest as planned.

Before I go on with my specific -- which will be very brief -- comments about it, I do want to mention one thing. The naturopathic profession, when we apply to the advisory council, we are confident that we are going to go through this process in a really effective and efficient manner. We do not expect, at least from our initial contacts with other professions, that there is going to be a lot of turf-grabbing or the other kinds of things that come with health care legislation, although God only knows, politics, if nothing else, is a surprise.

The Chair: There are probably a lot of members around this table who would agree with the last statement. Please continue.

Mr Labriola: What I would like to do is spend a moment and discuss what is new and different about the application process, specifically as our profession and other professions will go through it, and contrast that to the experience that the professions now in Bill 43 had experienced during the review.

The most obvious one is that we will be one profession in a fish-bowl. We will be there by ourselves, and this is in contrast to the review process where all of the professions were on relatively equal footing. We will be one profession absorbing the costs and burdens of the application process, the only one at the time. We will be in a position where we are critiqued by all of the other professions, and in fact maybe even having some of our turf attacked -- we do not think so, but that is an unfortunate fact of life in health care -- and this, once again, in comparison to the review process where all of the professions were relatively safe and equal in their approach to this process.

To put it succinctly, I think the profession that applies to the advisory council after the enactment of the bill starts out at some disadvantage, at least in those areas I discussed. I think the solution, though, is a simple one and it may be one that is already contemplated, but I feel the need, since we are going to limit our comments to that particular area right now, to at least go over them and express to you how we feel. We are hoping that this committee, and perhaps the ministry, will make a statement or a position that they are in fact enforced.

The first one is that the process remain accessible and reasonable to all professions, especially small ones. I think it goes without saying that a perfectly viable and useful health care option and profession in Ontario could be removed as a choice to the residents of this province by no other means than the paperwork level and the legal costs and other things involved in the application process becoming so onerous or so large that the profession cannot or does not know how to deal with them.

I think it is important that all requirements remain transparent and predictable. By transparent I mean that every requirement be absolutely clear as to what is expected, how it is expected, and when it is expected. I also think it is important that decisions be discussed during the process rather than after the process. There should be no surprises in the process -- once again, transparent and predictable. It may not change the outcome, but it will certainly allow our profession and other professions to proceed in an empowered way. I think that has certainly been the objective of this legislation.


Some limit on the amount other professions can lobby the advisory council and the ministry will be important. This is to minimize the turf-grabbing activity. I do not suggest that the council or this government or anyone is going to be susceptible to a lot of turf-grabbing activity. I do not think that has been the case; I do not think it will be the case. But by allowing a lot of lobbying and a lot of this kind of thing going on, it takes our valuable concentration and time away from the more important issues at hand.

Fourth, I think it is important that we recognize the uniqueness of professions, especially the naturopathic profession. If you try to understand naturopathic medicine by looking at us from a familiar model such as medicine or dentistry or chiropractic or whichever you choose, I think it is safe to say that you will never understand us. You will not understand the principles by which we operate; you will not understand how we achieve the results we achieve.

Carrying that a little further, I think the view of professions as a whole, and especially naturopathic medicine as a whole, is a very important concept for us to keep. You can almost compare the profession with the human beings whom we treat, and that is, the whole of the profession is much greater than the sum of all our parts. It is how the parts fit together, it is how they act, it is how they interact with themselves and with others that is very important. The very safest practice of naturopathic medicine is when it is practised as a complete entity. If the system were to inadvertently cut off an arm or a leg of our scope of practice, you would lose more than that one modality; you would really lose the balance and the interaction and the motion and the effectiveness of what is there.

Our concern about this, actually, may not be as great as the concern of some of our patients and practitioners right now; I am sure you are going to hear more about this. But I think it is at least worth enough mention that we go on record with our feeling about this. Let me, before I go any further, say another thing. We believe, and have always believed, that this law has been written by some very skilled and very reasonable people, some of whom are here today, and there is no question that it was intended to be fair. We have no doubt about that. We have never had any doubt about that.

I think it is also safe to say that any piece of legislation as large and as complex as this one will, if special steps are not taken, automatically favour the biggest and the strongest. It is a variation of Murphy's Law, and I think what I am suggesting here is that care be taken rather than that the initial intent being in any way faulty.

In summary, I would like to request several things of this committee: first of all, that we do in fact take special care to ensure that the playing field remains even for all professions in the implementation of this law, especially small professions. Second, I think we need to make certain that the sheer size and complexity of this act does not in and of itself and inadvertently overwhelm or undermine professions that are trying to operate within it. I am sure it will be inadvertently, and I mean that. But the fact is, this is a very large, complex act and we certainly would not want to see it, in effect, remove freedom of choice.

To put it another way, if we are going to be the only fish in the fish-bowl, and I think we are going to be the only fish in the fish-bowl when this starts, we would like you to at the minimum remove all harpoons from the first row of onlookers. We would like to make certain that the hoops we have to swim through are consistent with the public interest and are not expanded or retracted or changed in any way. Finally, if we are going to allow anything to be thrown into the fish-bowl and left floating, let's just make sure it is organic fish food.

Thank you. That concludes my comments.

The Chair: Thank you very much for a very interesting presentation. It is the first that has such graphic analogies.

Mr Jackson: I have some technical questions of the ministry to just explain the process. This group is included within the legislation for purposes of clarifying that they are not going to be deregulated, so this brings you within the ambit of the legislation. But we do not have a specific piece of legislation which sets out, as for all the other groups --

The Chair: I think the parliamentary assistant would like to explain the status and process, Mr Jackson.

Mr Jackson: I have some technical questions about the scope of practice, which we are discussing with some groups, but we are not in a position to discuss scope of practice with this group.

The Chair: You are correct. There is no piece of legislation before us today, except for the omnibus bill which they are speaking to.

Mr Wessenger: I will just refer that to staff counsel but, as I understand it, naturopaths are not directly covered under this legislation. They make application under --

Mr Burrows: Under this package it is true that naturopathy is not included. However, at first reading and again at second reading it was confirmed that the profession of naturopathy would continue to be regulated under the existing law until such time as the matter of its scope of practice could be reviewed by the regulatory advisory council.

As a point of clarification, I think maybe it addresses some of your concerns because the advisory council, as proposed in this package, would be composed of laypersons. There would be no bureaucrats and no members of the health professions sitting on the advisory council. Certainly, in developing the processes and procedures, that will support that group. It is anticipated that the process would be as open and transparent as the review process itself and perhaps even more so.

Mr Jackson: Conclusions always fascinate me more than processes. My concern is that we do not have a specific piece of legislation to replace the one we are leaving; presumably at some point we will. This group will not have the access to, say, this committee as all other groups do that have been advised that they are to be included.

The Chair: As I understand the legislative process, from my experience, which is similar to yours, Mr Jackson, the process would be for the government to table legislation at some future date, which could then be referred to committee for scrutiny. That that would be normal legislative process.

Mr Jackson: That is my understanding as well. I guess now we will ask the deputant. Is it your understanding that this the horizon you are looking towards, that you could anticipate legislation, as opposed to a regulatory framework, which could be covered by order in council? It is possible to rescind your legal coverage but have you covered by regulation?

You have been promised inclusion, but have you been promised inclusion with a proper bill setting out your scope of practice, or have you been told you will have scope of practice that could lead to basic regulations?

Mr Labriola: I am not sure exactly how to respond to your question. My understanding of the process that is coming forward is that we would be reviewed by the advisory council, at which time a recommendation would be made to the Minister of Health, and the ministry would then table legislation that would include our scope of practice and all the other issues, ostensibly in a manner consistent with Bill 43.

Mr Jackson: That is the point I am trying to get on the record, Madam Chair.

The Chair: For your information, Mr Jackson, in the package of material that was presented to you, you have statements on first and second reading, particularly by the minister and the former minister, which laid that process out and also made the commitment that regulation would continue under the Drugless Practitioners Act. I believe that is in the statement in Hansard.

Mr Jackson: I want to be assured it was a public statement. I was not here for the minister's presentation but, in my view, its continuing in a regulatory framework does not allow you the access to the process I think you are indicating you would wish to be part of.

The Chair: Those statements were made in the Legislature.

Mr Jackson: Yes, that is fine. I just wanted to make sure that was on the record. I have used naturopaths with great success and I appreciate it. I have also taken courses of naturopathy in the state of Virginia and I certainly was one who supported your regulating for access in this province. I am pleased that you have come this far and look forward to encouraging you in that regard.

The Chair: Thank you very much, Mr Jackson. There being no further questions, thank you very much for your presentation. If in the course of these hearings you feel you would like to submit anything further, please do so in writing.


The Chair: The next presenters, Jane Dely and Jennifer Giavedoni, are making a joint presentation. Please come forward. The committee has received your written communication. We ask that you take the next 10 minutes to give us your presentation and leave a few minutes for some questions at the end.

Ms Dely: Madam Chair, dear committee, we would like to thank you, first of all, for taking the time to listen to us today. I would like to introduce myself. I am Jane Dely. I am a certified dental assistant. I am a graduate of a community college dental assisting program. I am also a member of the Brant County Dental Assistants Association and the Ontario Dental Nurses and Assistants Association. Jennifer and I are two dental assistants who have worked in several dental offices over the last 11 and 9 years respectively.

Ms Giavedoni: My name is Jennifer Giavedoni. I am a member of the Dental Nurses and Assistants Association of Hamilton and serve on that executive, as well as being a member of the Dental Nurses and Assistants Association of Ontario. I have attended a private college for my training in dental assisting and have been certified for eight out of the 11 years I have been a dental assistant.

The existing legislation allows us to perform no intraoral duties. However, we feel there are many intraoral, in-the-mouth, services dental assistants can provide that do no harm, therefore we believe the proposal to leave these unlisted and in the public domain is correct and in the public interest.

Ms Dely: In Ontario, the practising dental workforce consists of approximately 5,000 dentists, 2,000 hygienists and 1,000 denturists. Of this group there are 10,000 dental assistants. This new legislation you are proposing would therefore better than double the useful workforce. This would certainly make for smaller increases in dental costs in the future.

Ms Giavedoni: In all of Canada, only Ontario and Newfoundland have not yet modernized and expanded the duties of dental assistants. We, and the literally hundreds of assistants we have spoken to, agree with this proposal. These are ordinary working people who are dedicated and want to be more useful in the community.

Ms Dely: At the present time we know of numerous assistants who are going out of province to British Columbia, Manitoba, Alberta and all the other provinces to upgrade their dental assisting skills. They are coming back with a level 2 status, or a PDA status, which is a preventive dental assistant. Ontario does not have this level as of yet. They are going out of province at an expense to them.

Our presentation has been brief today. We worked this morning and came down. On behalf of Jennifer, myself and all the other assistants we have spoken to, all we want to say is what you are proposing is good and should have been done a long time ago. We want to thank you for listening today.

The Chair: Thank you very much for a very good presentation before the committee. Any questions? It was very clear. If there are any questions members have in the future, I know they will be able to contact you. If you can think of anything further that you think the committee should know, please feel free to communicate with us in writing in the future. Thank you for appearing today.

The committee adjourned at 1534.