Thursday 22 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 Society of Clinical Perfusion

Chinese Medicine and Acupuncture Association of Canada

Health Care Aide Association of Ontario

Ontario Osteopathic Association

Len Boksman; Vikki Paquette

William Reid

Dennis Lebert

Louise Carroll

Gus Scheid

David Breznik

A. Dale Vellet

Jerry Banks

Tom Hebert

Barbara Conlon

Ian Galbraith

Interfaith Pastoral Counselling Centre

University of Waterloo School of Optometry

London and Area Association of Optometrists

London Regional Psychological Association

Ontario Association of Social Work Administrators in Health Facilities

London Birth Centre Committee

Midwifery Task Force of Ontario, London Chapter

Registered Nurses' Association of Ontario, Region 2

Ontario Association of Speech-Language Pathologists and Audiologists, London Chapter


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)


Cunningham, Dianne E. (Mrs) (London North PC) for Ms Witmer

Johnson, Paul R. (Prince Edward-Lennox-South Hastings NDP) for Mr Silipo

Miclash, Frank (Kenora L) for Mrs McLeod

Wessenger, Paul (Simcoe Centre NDP) for Mr Malkowski

Also taking part: Winninger, David (London South NDP)

Clerk: Mellor, Lynn

Staff: Drummond, Alison, Research Officer, Legislative Research Office

The committee met at 0903 at the Sheraton Armouries Hotel, London.


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. The standing committee on social development is now in session. I would like to welcome everyone and call our first presentation, from the Ontario Society of Clinical Perfusion. You have 20 minutes for your presentation. We ask that you begin by introducing yourself to the committee. If you will, please leave a few minutes at the end in case any of the members have some questions for you.

Mr Henderson: Good morning, ladies and gentlemen. My name is Mark Henderson. I am a clinical perfusionist at University Hospital and I am also the president of the Ontario Society of Clinical Perfusion. Reading the agenda, I am sure you must wonder what a clinical perfusionist is.

Mr Beer: It has been the key question all week.

Mr Miclash: We have been waiting for this.

Mr Henderson: Most people, even when I explain it to them, their answer is, "Oh, yeah."

A clinical perfusionist is an allied health professional who operates a heart/lung machine during cardiac surgery. To facilitate surgery on the heart and the great vessels, the function of the heart must be arrested. You can imagine trying to sew something that was pumping. It is relatively difficult. Therefore, the functions of the heart and the lungs are mechanically and chemically arrested. Our job is to run the circulation equipment that bypasses the heart and lung functions and circulates blood through the body.

The patient's life is totally dependent on the adequacy and the correctness of the cardiopulmonary support provided. Therefore, the clinical perfusionist must achieve a high degree of discretion and judgement to ensure everything goes well.

As an analogy, I have listed the cardiac surgeon being the pilot of a large aircraft, the cardiac anaesthetist being his navigator or flight engineer and the perfusionist being the ground controller. All three of them have a very important job yet all three are totally related and totally interdependent on each other.

In Ontario, the Michener Institute for Applied Health Sciences is the only place where cardiovascular perfusionists are trained. This is a post-graduate program and it requires previous health discipline experience. For instance, I was a respiratory therapist. Many are nurses. We have some who are doctors from other countries who are not licensed in Canada. There are people who have various degrees in research and applied critical care backgrounds.

The Canadian Society of Clinical Perfusion, our national body, offers a certification process whereby clinical competency is judged and certified. The process was developed with the Canadian society as well as the Canadian Society of Cardiovascular and Thoracic Surgeons, the Canadian Cardiovascular Society and the Canadian Anaesthetists' Society. What has been done is that graduates from the school, after a limited time, take a certification exam made up by these four bodies. The professional interests in Ontario, as you can see, are represented by the Ontario society and, nationally, by the Canadian society. The Ontario society is in itself a region of the national group.

There are certain concerns that I bring to you today. Where do the perfusionists fit into this new bill and what assurances do the public have that they will receive adequate care from a qualified perfusionist in Ontario?

We are a very small group. There are 50 of us in Ontario, approximately 150 in Canada. In the United States there are very many more because of the large number of hospitals that do cardiac surgery. There are large companies of perfusionists in the US. One perfusion company does over 10,000 cases a year. They have their own Lear jets and buses. They can do cardiovascular surgery on the roadside if they wish.

We are concerned that a small group such as ours in Ontario will be lost within a large bill such as this. We are trying to maintain our identity. The main reason is that it is very easy for another profession to come in, say it could do our job and not do it adequately. The public would suffer. We are concerned that there is a mechanism available to ensure that only Canadian-certified perfusionists are employed in the province to perform recognized tasks and be protected from imported staff with questionable credentials, as has happened in the past. Any imported staff may come from other countries, as it has, or may come from within our own country.

I was wondering if you could address these concerns that we have and hopefully shed some light on them.

Mr Owens: Where do you see yourselves fitting in in terms of where you would like to be regulated? Would you like to be regulated as a group unto yourselves, or do you see yourselves fitting in as a tagalong, say, with physicians or something like that?

Mr Henderson: I think it would be very difficult for us to tag along with another group, to be put as a subsection as another group, because our job is so unique from any other profession we have come across. We would very much like to see ourselves as a unique group within this.

Mr Owens: So you would see yourselves as having the availability of numbers to have your college and the various committees that would be required under self-regulation?

Mr Henderson: I think that would be very difficult for us to do yet. At the same time, we are fairly adamant that to be put under another group would only cause our profession to be diluted and the patient to be put at somewhat of a risk.

Mr Owens: So then you might see yourselves, rather than being added into the bill itself through regulation, having the various standards of practice of your profession set out?

Mr Henderson: Yes, we have our own standards of practice that are set up on the national level. The provincial society has adopted those as well. We would like to see those recognized if we could.


Mr Beer: In regard to the questions you have asked us, it might be helpful for the witness, in terms of how they would in fact be regulated with this act were it to come into play the way it is -- I realize the parliamentary assistant is not here -- if we could direct that to staff in terms of how that would work out.

The Chair: With the wish of the committee, I will ask the ministry official, Mr Burrows, to respond to the questions that have been raised.

Mr Burrows: Would you mind repeating the question?

Mr Beer: The essential one, I think, would be, where do you fit in with the legislation that is going forward and, I suppose, how in fact are you then regulated or how do you proceed with your work? I think that has been a question for a number of groups which do not have a specific act. It would be useful to have that on the record.

Mr Burrows: The process that led up to the legislation was the Health Professions Legislation Review. I am not familiar with whether your group was a participant in the review. I do not recall that it was. That being the case, there is an advisory council to be established by this legislation which would be independent of the bureaucracy and independent of the health professions. It would in a way carry on with statutory authority the kind of work the review did. It would look at who should continue to be regulated, whether new groups are emerging, new technologies that the public needs protection from because they are potentially harmful and, in essence, any issue related to professional regulation.

The thought is that as a result of this legislation, that advisory council to the Minister of Health would exist. They would look at any submissions that were made, or anything that was recommended by the minister, applying criteria. Probably to start with, they would use criteria, if not the same, at least similar to those used by the review to deal with those very same questions.

In terms of regulation, though, there are other forms of regulation. One of the criteria of the review is, is the group effectively regulated in some other way? For example, if you practise primarily in the hospital setting, then clearly there would be provisions in the Public Hospitals Act to govern the activities of health professionals working in that setting. That is a question you would have to address.

Of course, we have many professionals who are regulated in other ways but who are self-regulating too. Then they look at criteria such as numbers; for example, are you able to finance self-governance? Those things are all questions that would have to be addressed. Certainly my branch of the Ministry of Health would be happy to work with you and answer any questions you have, if you want to get ready for that process when the time comes.

Mr Beer: Just in closing that off, I think the fact that because within the legislation is the creation of the advisory council expressly there, for newer groups, as was mentioned, or perhaps ones that we as laypeople are not as familiar with, there is an ongoing process in terms of looking at how they ought to be regulated. That is probably the most effective course for your organization to take once the legislation is in place.

The Chair: There was one other question that was raised by the deputant. With the permission of the committee, I would just put it on the record. You raised the issue of immigration to this province. Do you want to ask the question, Ms Haeck?

Ms Haeck: Yes, I do. I had occasion since I have been elected to meet with someone who had in fact, as a Canadian, taken a course in a United States college and then had to deal with the Canadian regulatory body. In this case, it was also a respiratory technotherapist and she fell under the regulation of that body. As the organization that would be ultimately regulating whoever enters your profession, would you not see that as a safeguard in dealing with whoever might be emigrating from the US or some other country?

Mr Henderson: Currently there is no reciprocity between the Canadian certification standard and the American certification standard. Officially they are both recognized across the borders as being in place. I think there are only minor safeguards available right now for having people come into the country, practising perfusion in Canada and in Ontario, people who are questionable credentially. It has happened in the past.

Ms Haeck: As far as employers are concerned, obviously when they are advertising for this particular job, there are certain credentials or criteria, education background that they are looking for. Is it considered basically a reciprocal arrangement, with the qualifications of the individual coming from the United States bearing the same weight with the employer as yours? Or is this in fact an area where your organization can work with the hospitals, through the doctors performing this type of surgery, to impact on the hospitals to say our educational qualifications are such that we should be limiting who is employed from other countries?

Mr Henderson: The Ontario society has contacted the Ontario Hospital Association and made recommendation to its members that they only hire Canadian-certified perfusionists to work in Ontario, so that the Ontario society, our group, would have some means of recognizing the credentialling these people have. There was a big concern some time ago in Toronto when a large group came from the United States to fill a large void in the employment. They said it was not their mandate to do this, and that they would not make that recommendation to the hospitals.

We have asked our members to take it back to their own hospitals and make those recommendations. However, we are getting mixed response from individual hospitals.

Ms Haeck: I did have one more question, which follows on some of the comments Mr Burrows made.

The Chair: I have a question from Mr Hope.

Ms Haeck: Okay, that is fine, thank you.

Mr Hope: I understand, through the study, you are involved in the consultation process because of the new technology. Do you see a growing need in the profession as the technology improves? Will you see changes in your job as technology improves?

Mr Henderson: Over the past few years it has changed quite a bit. I have been a perfusionist for just under 10 years now, and we have changed quite a bit as the technology is making leaps and bounds. As you know, as the need for cardiac surgery increases, so does the need for a perfusionist and so does the need for increasing technology.

We have hit somewhat of a plateau as far as technology goes, only because we are limited to the equipment that is available to us. However, the applications of the equipment now are progressing ahead. The patients that we see are progressively getting older and sicker, and we are able to be very successful in taking care of these patients. I think the need for perfusionists will grow as the need for cardiac surgery grows.

Mr Hope: To follow up on that, as the technology changes and so do the requirements change, I have to propose a question dealing with the general public, as to how the quality assurance is there to the individuals.

Mr Henderson: That is what we are concerned about. Being a relatively small group, we have taken it upon ourselves, through the education and certification process, to ensure that the quality is there from graduation of the students.

We work with the CMA in the accreditation of all clinical training sites and through our recommendations; we recommend that the people be certified before the hospitals employ them. Right now we are at that stagnant point of trying to get the hospitals to agree to follow our guidelines.

The Chair: There are a couple of minutes left. I would like to ask a question. Do you know of any profession practising in Ontario today that has a mandatory, ongoing, continuing education requirement for maintenance of its certification?

Mr Henderson: Not to my knowledge. I know that perfusionists have an ongoing maintenance of certification. There are certain criteria that a perfusionist must maintain in Ontario and in Canada to maintain certification.

The Chair: To maintain certification by whom? Who does the testing?

Mr Henderson: The Canadian Society of Clinical Perfusion.

The Chair: Do you have a relicensure every so often, where you have to prove that you have maintained your credentialling?

Mr Henderson: Every two years.

The Chair: But there is no college that enforces that.

Mr Henderson: No, we do not as yet have a college.

The Chair: The comment I wanted to make was to just inform you of the report on access to trades and professions. I thought it might be helpful if you made yourself aware of that, and also became aware of immigration policy in the country, which has effect -- attracting where there are labour shortages and so forth -- as well as the fact that there are no interprovincial mobility barriers for labour in Canada. Generally it is the employer that sets standards of and criteria for hiring, for job requirements. I just thought you might want that information on the record. You could then look through those documents, and if there are any additional questions that you have, I would encourage you to meet with ministry officials.

Ms Haeck: May I just quickly ask the one question I had left, which was how many actually are working in the field? As far as your being able to sustain yourselves and follow all of the requirements of this act as a self-regulating profession, you do need some numbers and financial resources to maintain about six committees. How many people are working in that field?

Mr Henderson: That is the big stumbling block for us now. There are approximately 50 in Ontario and about 150 in Canada.

Ms Haeck: I see. It is a small group.

Mr Henderson: Yes.

Ms Haeck: It is very essential, but it is a small group.

The Chair: Thank you very much. We appreciate your presentation today.



The Chair: I would like to call next the Chinese Medicine and Acupuncture Association of Canada.

Dr Cheung: Good morning, Madam Chair, members of the standing committee and ladies and gentlemen of the audience. I am thankful for this opportunity to address this committee regarding the prohibitions of Bill 43 and the subsequent exempt status of Chinese medicine and acupuncture. It is also my intention to convey the urgent need for the legislative regulation of this profession.

Chinese medicine and acupuncture was first introduced into Canada in the late 1800s by the early Chinese immigrants. Over the years, this form of health care has become exceedingly popular as a result of the holistic trend towards health care when conventional western medicine has failed to meet the needs of health care consumers.

Attempts for regulation of this profession have been made to the past governments of Ontario. It is our hope that legislative recognition by the government of Ontario of Chinese medicine and acupuncture as a separate and distinct profession will ensure the following: (a) to enable health care consumers seeking Chinese medicine and acupuncture treatment to be attended to by a qualified practitioner of Chinese medicine and acupuncture; (b) to make provisions to provide medical insurance coverage for health care consumers who require acupuncture therapy; (c) to assist in reducing the current health care budgetary deficit.

In terms of the qualifications for the practitioner of Chinese medicine and acupuncture, I would like to direct your attention first to the videotape.

The acupuncture inserted here on the human subject -- as you see, the needle in the back of the head, in the back of the skull, is as deep as one and a half inches there. If it is inserted too deep, it can injure the medulla oblongata and cause death. The needle on the shoulder there, if it goes too deep, can puncture the lung and cause pneumothorax. The needle on the back there is corresponding to the kidney location. If it goes too deep, it can puncture the kidney.

On the ear acupuncture there, although the needle is a lot smaller and shorter, proper insertion and manipulation still have to be stressed. If not and if the cartilage of the ear is injured, that can cause inflammation and, as a result, the patient may lose the ear. That has happened in China when it was practised by unqualified practitioners. The patient's ear cartilage was inflamed, and as a result she lost the ear. In taking out the needle beside the eyeball, that also went as deep as one and a half inches.

This review simply indicates that any practitioner performing acupuncture has to be well trained and qualified and competent to do it. It is not a matter of 30 hours of training, then you can go into a hospital or any clinic facility to treat patients. Of course, without doing it properly, that can also influence the effectiveness of acupuncture. It is very important. It is not just inserting needles there. There is a lot behind it.

Basically now in Ontario, there are three groups of people practising acupuncture. The first group would be the members of my organization; 70% of them are from mainland China and the 30% come from the other parts of Canada and other countries. Of course they are very qualified, and there are strict criteria of selection of the membership.

The second group would be licensed medical doctors, chiropractors and physiotherapists. They may be qualified in practising their own disciplines but may not necessarily be competent in practising Chinese medicine and acupuncture. There is an organization in Ontario that is being used to train licensed medical doctors and physiotherapists for 30 hours, and then they let them practise on their patients. Now they may increase the number of hours to 100. Still, it is not sufficient. With that kind of deficiency in their training, the patient recovery would be prolonged. That will in turn increase the health care costs.


The third group of people would be individuals who have no basic medical training at all, but they go a country like Sri Lanka for four to six weeks and come back with a certificate or degree and post themselves as qualified acupuncturists. There are many of them doing it in Ontario. In London alone, from what I know, there are at least 20 of them already with a certificate from another country practising and posing as qualified acupuncturists in London.

It is of great concern to my organization that the exempt status of acupuncture will allow these individuals, who have no basic medical training and only a four to six week course of study, to cause great danger to the public. Our intention is that the Western medicine doctor and the Chinese medicine doctor must work together in harmony to provide the best possible care for the people of Ontario. Therefore, legislative recognition is the best means of achieving this goal.

In China a doctor of Chinese medicine and a doctor of Western medicine have equal footing. In the state of Nevada a doctor of acupuncture, a doctor of herbal medicine, a doctor of traditional oriental medicine has a degree given by the state of Nevada government. That takes four years of study besides two years of university. In the state of California the same number of years is also required.

I do not want to go into further detail about the economics of Chinese medicine acupuncture. I would like to stress though, utilizing Chinese medicine acupuncture in the health care system of Ontario will in the long term reduce health care costs of Ontario.

Due to the unregulated nature of this profession, patients are subject to paying the GST for health care. My organization is of the opinion that health care should be GST-exempt. It is most unjust and certainly lacking compassion and humanitarian concern by the government of Ontario for health care consumers.

My organization has seven chapters across seven provinces in Canada. I am the national president of CMAAC. My organization is also a member society of the World Federation of Acupuncture Moxibustion Societies. The headquarters is Beijing. WFAS, which is short for the World Federation of Acupuncture Moxibustion Societies, is also fully recognized by the World Health Organization and works in very close collaboration with WHO to promote Chinese medicine acupuncture around the world and to benefit all of mankind by the year 2000.

In closing, we strongly feel that the protection and the best interests of the general public in regard to health care must be an urgent priority of the government of Ontario. By incorporating Chinese medicine and acupuncture into the existing health care system, the current health care budgetary deficit can be minimized in the long term; there are already precedents in other countries like the United States, England or France. By minimizing health care costs, this in turn will decrease the tax burden on the general public. Also, it is CMAAC's hope that this proposal will assist in making the health care system in Canada more efficient and that WHO's goal for all by the year 2000 will be realized.

Mr Johnson: Thank you, Dr Cheung, for your presentation. I found it most interesting and certainly I have had a long interest in the medicine of acupuncture. I see that you are a doctor and that, I guess, would mean that you are a medical doctor as well.

Dr Cheung: I am a medical doctor in China, but I am not a licensed MD here.

Mr Johnson: You are not a licensed MD here?

Dr Cheung: No, but I have training in both disciplines.

Mr Johnson: I was curious. I saw those needles being inserted into the body and they go quite deep. You indicated that if they were not done exactly correctly, serious consequences could result. I am curious to know, have there ever been, in Ontario, any lawsuits or litigation as a result of improperly practised acupuncture medicine?

Dr Cheung: Fortunately there is nobody yet seriously harmed. In my practice, in my clinic, I have received quite a number of patients that have not been treated properly and have also developed some side effects like abdominal pain or swelling of the leg due to the improper insertion of a needle.

But I would like to point out we should not wait until something serious happens. This is common sense. When you are taking a needle and inserting it into a human body, if it is not done properly by a competent practitioner, danger can ensue automatically. I do not want to wait until some death occurs before your government does something.

Mr J. Wilson: Thank you, Dr Cheung, for your excellent presentation. You raised a number of very good points. On the basis of your presentation, it does appear to make sense that it should be regulated for the protection of the public and for the profession itself. I was just wondering, did you appear before the Health Professions Review Legislation? Subsequent to that, why was acupuncture and Chinese medicine not recommended for regulation at that time? Are you aware of reasons given by government?

Dr Cheung: I delegated my colleagues to appear before the Health Professions Legislation Review. At that time, im my recollection, the government believed acupuncture did not pose any risks of great danger to the general public. Therefore, they did not regulate it. That was the decision they took at that time.

Mr J. Wilson: So it did not fit one of the criteria set out by the committee.

Dr Cheung: That is right.

Mr J. Wilson: Secondly though, if I may, Dr Cheung raises a very good point about controlled acts and that acupuncture does involve the insertion of needles below the dermis. Perhaps we could have a clarification of that for the record. I just want to make sure they are able to carry on the practice of acupuncture and are not in any way impeded by this legislation. Perhaps we could have a clarification from counsel on that.

Mr Burrows: The previous government and the current government have both confirmed, on introduction of the legislation, that there would be a specific exemption by regulation for acupuncture, ear-piercing and a number of other invasive procedures.

The rationale for not including acupuncture as a self-governing profession was based on essentially two things: There was not a proven risk of harm other than possibly the transmission of disease. It is anticipated there would be a supplementary amendment to another piece of legislation dealing with public health to ensure sanitary procedures were followed, because there are two reported instances of transmission of AIDS in the United States, so it is the ministry's intention to introduce complementary amendments in another piece of legislation to ensure that occurs. The other criterion that was not met was the regulation of a person's doing this activity. Quite a number of the practitioners in this province in fact are already members of other regulated professions, for example, naturopathy, chiropractic and even medicine.


Mr Beer: How many members do you have in the Canadian organization?

Dr Cheung: In my organization we have close to 600 members across Canada. In Ontario alone we have approximately 250.

Mr Beer: You outline in your brief the three different groups that might be practising acupuncture. In group two, which you noted was composed of licensed medical doctors, chiropractors and physiotherapists, how many would be practising acupuncture on a regular basis?

Dr Cheung: I think quite a number of that group are practising acupuncture. Many family doctors, chiropractors and physiotherapists do. If you add them up it will come to a big number. The idea is they may not pose great danger to the general public, but they will lengthen a patient's recovery period and that will increase the costs. To practise acupuncture is not so simple, as I indicated earlier, as just inserting the needle. There is certain training. That is why in China it takes six years to be a doctor in Chinese medicine. In London, we have a school. We also take six years. To get into school or my organization, applicants have to have two years' university. Then it is four years' intensive training.

The Chair: Thank you very much for your presentation this morning. If there is any additional information you think would be helpful to the committee, you can submit briefs in writing through our clerk at any time and also, as mentioned before, this legislation suggests there will be an advisory council available for your organization to take the matter further.

Dr Cheung: Thank you, members of the committee.


The Chair: I call the Health Care Aide Association of Ontario. I would ask that you come forward. Begin your presentation by introducing yourselves to the committee. You have 20 minutes for your presentation and we ask you to leave a few minutes at the end of your formal presentation in case members have any questions to ask. Thank you very much. Please come forward, have a seat before the microphones and begin your presentation now.

Ms Robbins: Good morning. I am Mona Robbins, health care aide, president of the Health Care Aide Association of Ontario. With me are Sheryl Stephens, health care aide, and Doreen Smith, health care aide, who is on the education committee for the association.

In the last few years, my colleagues and I have become increasingly aware of the necessity to have an organization exclusively concerned with the problems and needs of the certified health care aide and the chronically ill. We are here today to speak for the most vulnerable patient in our society. We are here to ask that we guard against the exploitation of the chronically ill, disabled and the elderly.

With this evolution of change in the health care system today, the elderly and the disabled will remain in their homes longer. We agree that beds in hospitals should be left open for acute cases; we agree that the elderly and the disabled should be kept from behind bricks and stones, but we must also agree that the resident who will be admitted to the long-term care facilities will be heavier care and chronic care.

I have enclosed a recent London Free Press newspaper clipping about a couple who hired a person who was hitchhiking; they picked him up as a hitchhiker and hired him supposedly as a health care aide and they scalded a patient to death in the bathtub. In this paper it says here, "Evidence showed most of the home's health care aides were unskilled labourers."

Daily we read in the newspaper of harm, neglect, sexual abuse, physical abuse, not to mention verbal abuse, that is inflicted on the most helpless, the elderly and the chronically ill. We should not leave it to the employer who is in business for profit, or nursing home inspectors. In nursing homes, homes for the aged, retirement homes and the community, it should be made mandatory to take advantage of hiring trained, qualified, certified health care aides. This could be an added deterrent in keeping such tragedies from occurring.

It is everyone's concern to protect our ever-increasing population of elderly and chronically ill and to see that they are provided with proper and qualified care. The definition of quality care is caring for both body and mind and it is directly related to the knowledge and resources a person possesses, thus enhancing the quality of life.

The unqualified worker has no place on the job. They jeopardize health and safety to the residents and also to the staff. You cannot learn intensive bedside nursing in two days of orientation. You cannot learn and be aware how important it is to use safety devices or good observation skills and how important it is to communicate these observations. Good observation skills can save and have saved lives of the helpless and safety can save broken limbs or fractured hips. In two days you cannot learn feeding techniques to prevent choking and aspiration. The list goes on.

We must also keep an open mind, not just including our locality but across the province. In a small community it is different. There we know each other's families, but in large cities you do not get to know or see the family. Some long-term care facilities only hire young high school students and part-time staff. This creates a large staff turnover which creates an undesirable environment and lack of consistency.

The newly formed Chartered Health Care Association of Ontario seeks recognition and acceptance for its members for the specialized nursing they perform. We are a large group of people working in the medical field, and certified health care aides are primarily responsible for providing hands-on intensive bedside nursing care in long-term care facilities.

Certified health care aides are in the community; certified health care aides hold positions such as administrators of retirement homes and certified health care aides hold licences to manage facilities to care for patients for the transition from hospital to home. Also, certified health care aides hold positions in doctors' offices. We too are concerned and responsible for the person in our care. Since the consumer is the most important person in nursing homes, homes for the aged, retirement homes and the community, we seek to gain his or her trust in our competence and our ability. We do not want to allow the reputation of the certified health care aide to be undermined by being mistaken for NAs, nurses' aides, since this would reflect back on the bedside care giver.


It is also the certified health care aide who is the link and who works closely with other members of the health care teams, such as physiotherapists, registered nurses and doctors. We do more than dress, feed, toilet, wash and stick our patients in a wheelchair. We understand the process of aging, the terminally ill, the psychological aspect of giving up.

Our work involves taking vitals; observing mental, social, physical changes and recording these; active and passive physiotherapy exercises; repositioning to prevent pressure sores and contractures; collecting specimens and other nursing things in the scope of practice; assisting to develop nursing care plans; participating in team conferences, and palliative care for the dying. We are trained to work at the bedside; we are the front-liners.

Remember, when a patient who in many cases is helpless calls out "Nurse," it is the health care aide who answers. To the resident, whether health care aide, registered nurse, registered nursing assistant, certified health care aide, we all look alike. A nurse is a nurse. We are bedside specialists in times when nursing is getting farther away from the bedside. Many chronically ill have no one to speak for them; they have no family. They are alone, they put their trust in the care giver.

One of our objectives is to maintain the high standards and ideals of the certified health care aide. The workload and heavier care and more complex care is steadily increasing. We care for people with Alzheimer's disease, multiple sclerosis and other debilitating diseases. We must have the knowledge to keep pace with the changing needs and ensure the highest quality of care. We also need to see the level of preparation upgraded. We need to update and improve the certified health care aide program. Also, the certified health care aide in the community will need to be more knowledgeable. We need more certified health care aides, as we are always working short-staffed. We are making an appeal that the $647 million aimed at the elderly and disabled will be towards more staffing in the long-term care facilities.

We would like to see improved education and a right to legally practise more of what the certified health care aides are taught in health facilities. For example, health care aides cannot take a person's blood pressure, so the teaching system has been changed to reflect that. However, many establishments will teach the procedure once the worker is under their supervision. Many health care aides feel the procedure should be inclusive in their duties because blood pressure is an important vital sign. Many establishments feel that certified health care aides are competent and, when the workload is heavy, will designate treatments and blood pressures.

At this time the health care aide course is offered at community colleges, secondary schools and as a two-week professional development program. We are a large group of people working in the medical field without provincial standardization of course tests or disciplinary action of negligent members. We wish to establish standards instead of guidelines. Our goal is to have the curriculum content of all health care aide programs basically the same and to have standardized provincial exams for all students. Standards would provide guidance for certified health care aides, educators and employers.

We seek to promote nursing excellence and quality nursing care. We would like classroom training to teach principles and procedures of practical work and training in cleanliness and efficiency. There should be practice in demonstration rooms before being allowed to care for people. Nurses' aides should not be allowed to be hired right off the street, having just worked in factories with no medical knowledge whatsoever. We would like to see all health care aides graduate from an accredited college health care aide course.

We are utilized by being called upon to do non-nursing things such as laundry. On the other hand, when workload is heavy, we are designated duties such as vitals and treatments. Also, this is a high risk for potential infection spread, handling contaminated laundry and then caring for the patient.

We would like to be registered with the health professions legislation disciplinary act. This would give us licensing as a professional and competent person. We would be assured of our competence and of the competence of our colleagues. Under the legislation health care aides could be monitored. We would also like to establish a disciplinary committee to deal with harm, neglect, physical and verbal abuse. It is a sad situation, but we need to protect the public by investigating complaints about nursing practice and professional misconduct or incompetence of its members. A prevention method used for disciplinary purposes would result in better nursing care.

Because patients and the public are the most important people in the reform of Ontario's long-term care service and our first consideration, the association would like to establish maximum protection to the public. We feel there should be a standard-of-care clause established as well as a scope-of-practice clause. We would like to be registered with the Regulated Health Professions Act and wish to gain its support as we feel all these things would fall into place.

A summary of what the association would like to establish: licensing through registration; provincial exam; a disciplinary committee; improved education in chronic gerontological nursing; a right to practise more of what a health care aide is taught; to promote close relations in the provision of health services and help create an environment in which health professions can work together co-operatively and effectively, and high standards and ideals.

On the last page of my summary I would like to bring to your attention that the Nursing Homes Act states health care aides give only personal care, for example, dressing and grooming. Health care aides do more. Health care aides give the scope of practice that is in the Nursing Act.

The health care aide is the practical nurse and gives all hands-on bedside nursing in chronic and geriatric long-term facilities. We promote health and recovery and relieve pain by reporting it to the medication nurse. Health care aides meet basic physical, supportive, preventive, therapeutic, palliative and rehabilitative needs in order to attain and maintain normal function. Health care aides observe, report and communicate changes in residents' physical or emotional status. The physiotherapist often only comes in twice weekly. Health care aides continue physiotherapy when the physiotherapist is not available. We are called upon to assess and give input in nursing care plans. We have a legal responsibility to the person in our care.

I also would like to bring to your attention that the Nursing Act states that it is a nursing act performing invasive instrumentation, including manual and digital instrumentation beyond the anal verge. Health care aides take rectal temps, glove, and administer enemas and suppositories and more.

The Nursing Homes Act states that laundry, etc, does not count for nursing hours. Example, there are 107 patients to six health care aides on a shift. That leaves five health care aides for 107 patients, as one health care aide is down in the laundry most of the shift, which takes away from nursing hours. We would like to see all six in nursing care. Also, cross-contamination becomes frequent.

Health care aides also hold administrative positions such as administrator of rest homes, making important decisions daily such as setting standards to ensure quality care and efficiency within the establishment. Four ministries developed the health care aide program. We would like to see the health care aide role be reassessed and redefined and serious attempts made to raise the health care aide nurses' standards and to encourage a better class of recruits.

We look forward to your participation in the planning for the future role of our profession. Thank you.

The Chair: Thank you for an excellent presentation. You did not look nervous at all.

Mrs Cunningham: I would very much like to thank you for being here today and for all the work you have done in the past, especially in the last couple of years as you have gotten your organization together and worked hard to do that. What is your membership now within your own organization?

Ms Robbins: We are just starting out and that is our problem. We are trying to do everything and we only have about 400 members so far, but we have chapters in Sault Ste Marie, Ottawa, Oshawa and London.

Mrs Cunningham: That is great. I am certain you will have a lot more members. When you say only 400, that is a lot to this committee.

Mr Hope: You raised a number of good points, such as accreditation by community colleges. I know currently that community colleges have health care aide systems in place which require a certain standard. I can speak of that because I know the in-depth basis of the education that takes place.

When you make mention of the long-term care reform and long-term care facilities and home-based service, would that not be more the responsibility, as we see in rest homes and private enterprise, where they are the ones who are hiring the non-registered, the nurses' aides, versus the community-based ones who are hiring qualified people? Is that not the case as to what is happening?

Ms Robbins: No. They are hiring people right off the street, right from factories. That is why we are asking, please do not leave it to the employers any longer. The health caree would like to see all qualified people hired, and this is one way we could monitor that.

The Chair: We appreciate your coming before the committee this morning. If at any time there is anything else that you think would be helpful for the committee during our deliberations, please feel free to communicate with us in writing through our clerk.



The Chair: Next is Douglas Lauder of the Ontario Osteopathic Association. Are you here representing the association or are you here as an individual?

Dr Lauder: I am past president of the Ontario Osteopathic Association and I am representing that association. Mine is a short presentation, as you can see.

In recent years, the terms "osteopath" and "osteopathy" have been replaced by the terms "osteopathic physician" and "osteopathic medicine." The enclosed photograph of my licence to practise, a government of Ontario certificate, uses the term "osteopathic medicine," and this document is dated April 25, 1955. These newer terms are seen to be well established over time.

The osteopathic profession recommends that in Bill 55, An Act respecting the regulation of the Profession of Medicine, subsections 16(1) and 16(3), the word "osteopath" be changed to the term "osteopathic physician." That is my recommendation.

Mr Beer: We have had a number of questions around titles, and I think as laypeople, it helps us to understand better why these terms have evolved or what it is that is trying to be expressed here. Is it simply that this is the way in which your profession is referred to and that is the language you want, or does that term "osteopathic physician" say something more, say something else besides the meaning of the terms that are in there, where it says "osteopathic physician or surgeon"? I wonder if you could just help us with that.

Dr Lauder: The term "osteopathic physician" probably takes the connotation away from a separate profession and into the general medical profession. This is the case in every jurisdiction in the United States, for example, where every state recognizes osteopathic medicine fully and completely, the same as a medical physician. This also has taken place in the province of Alberta and in the province of Quebec, except that of course in Quebec there is a language problem. The examination has to be written in French and we do not have anybody who can do that.

These are situations that have taken place and I think that perhaps explains why we prefer the terms "osteopathic medicine" and "osteopathic physician" rather than "osteopath" and "osteopathy."

Mr Beer: Could I then ask, through the parliamentary assistant, did the review consider using this term, and if so, was there any specific reason why they decided to use the terminology that is currently in Bill 55, subsections 16(1) and 16(3)?

Dr Lauder: Those were the original terms years ago, but they really have been replaced by the ones that I have requested.

Mr Burrows: Not having been part of the review on this issue, I honestly do not know what the review considered. However, I can say that the review concluded there was no need to protect "medicine," but the title of "physician" would be protected to members of the College of Physicians and Surgeons of Ontario.

I would point out that the profession of osteopathy, it is envisioned, would be governed, along with physicians and surgeons, by the College of Physicians and Surgeons of Ontario. The review envisioned that there would be a special register for osteopathic practitioners. Really, the recommendations stopped at that point. It is envisioned that in the writing of regulations, issues between the governance of orthodox North American medicine and osteopathic practitioners would be worked out between representatives of the two professions. A great deal of detail has yet to be done in that area.

The Chair: We appreciate your presentation before the committee. If there is anything that you think might be helpful over the course of our deliberations, please continue to communicate with the committee in writing.


The Chair: I would like to call next Len Boksman and Vikki Paquette. You have 10 minutes for your presentation. We would ask if you would leave a few minutes at the end in case members have any questions.

Dr Boksman: I am Dr Len Boksman. As a 1972 graduate of the University of Western Ontario, I am currently in private practice in general dentistry in London, Ontario. I am also a part-time faculty member in the faculty of dentistry at the University of Western Ontario. I have authored and co-authored over 50 scientific papers and a text on dental techniques.

I am here today with Mrs Vikki Paquette, a valued member of my health care team whom I will introduce to you shortly. We welcome this opportunity to address your committee, not as representatives of a special interest group, but simply as health care practitioners who are concerned for the wellbeing of our patients.

In this regard, we have some very specific concerns regarding Bill 47 as it is currently drafted. Under section 3, the scope of practice states, "The practice of dental hygiene is the assessment of teeth and adjacent tissues and treatment by preventive and therapeutic means." It goes on to state that the provision of restorative and orthodontic procedures and services is on the order of a dentist. This latter portion is consistent with section 4, which lists the authorized acts.

Our concern arises from the fact that the part just previously quoted, namely, "treatment by preventive and therapeutic means," is not on the order of a dentist and is therefore not consistent with the authorized acts as described. In fact, it would imply independent practice by hygienists. It is our strongly held belief that this would result in serious shortcomings to the wellbeing of the public and should therefore be reconsidered.

At this time, I would like to introduce to you Mrs Vikki Paquette, a registered dental hygienist, who can elaborate on this matter. Mrs Paquette, an honours graduate of Cambrian College, has been in the field of dentistry for 16 years, 13 of those as a practising dental hygienist. During this time, she has had the experience of working with a number of dentists in several cities throughout Ontario.


Mrs Paquette: I would like to begin my comments by thanking the committee for the opportunity to express our concerns. I hold what I believe to be a widely held view by my colleagues in the profession of dental hygiene, namely, that our patients are best served by a team approach to their dental needs. The team concept as currently practised creates many benefits for the patient. It ensures that the patient is seen by two professionals complementing each other's skills, which results in complete care. This type of approach also leads to in-house quality control and minimizes the risk that something vital to the patient's care might be missed. Our patients deserve to receive a diagnosis by a dentist. It is our belief that the current RHPA proposals will break the team approach to the delivery of oral health services. To us, the most effective and efficient care is achieved when the dental hygienist functions in collaboration with the dentist.

We do not believe that comprehensive oral health care can be achieved if the dental hygienist establishes practice apart from the dentist. We believe that the current proposals under the RHPA will lead to the fragmentation of patient care, and this cannot be in the best interests of the public. To quote from the past president of the Ontario Dental Hygienists Association, "Dental hygienists cannot function in a vacuum independent of dentistry nor do they want to do so."

It has been stated by some that the current legislation will allow better and more affordable care for our seniors in nursing homes. People are living longer and, with enhanced preventive care, are keeping their teeth longer as well. Surely there is a role for the hygienist in the care for the elderly. However, we cannot endorse a role which would include the provision of treatment services for any patient group without the benefit of a diagnosis. To do otherwise could place the patient at risk.

Institutionalized seniors are generally medically compromised. The complexities of their health status must be weighed carefully prior to establishing any oral health treatment plan. Patient management of the elderly begins with a diagnosis.

Cost containment must not dictate dramatic changes to the scope of practice granted to any professional group.

This whole dilemma has a simple solution. To shift the phrase "on the order of a dentist" just prior to the phrase "treatment by preventive and therapeutic means" in the scope of practice section would serve to give my profession greater freedom compared to the current act which requires direct supervision on the part of dentists and would serve to protect the public in that the team approach would remain intact.

In summary, it is our sincere hope that this committee will review the proposed scope of practice statement for dental hygienists and bring forward amendments to ensure that dental treatment services are provided on the order of a dentist.

Mr Johnson: In your presentation, you mention some of the serious shortcomings to the wellbeing of the public that could result, in your opinion, if the changes are not made that you request. I was wondering if you could elaborate on what these serious shortcomings might be because I think that the relationship is a good relationship, but I am not sure that the workhygienists do really necessitates being seen by a dentist prior to some of the functions that occur. If you could elaborate on that, I would appreciate it.

Mrs Paquette: I would like to answer that question, if I could. I believe that there is harm to patients by, for example, an independent hygienist. The risks are very severe for the medically compromised patients. Someone with a heart murmur, history of rheumatic fever or any artificial knee, prophylactic valves, are under the risk without any pre-medication that they may run into subacute bacterial endocarditis, which can be fatal. I am not licensed to give an authorized pre-medication; therefore, the patient would have to go back and get a prescription from the doctor. It is not only that they are at risk, but it is very inconvenient.

Mr Johnson: How often would this occur?

The Chair: I have other questioners, Mr Johnson. Thank you.

Mr Beer: Just to in effect follow along in the same line of questioning, we certainly agree with your idea around the team approach, and I think that is what we have been getting from many health care practitioners. But also recognizing that we are trying to widen accessibility and choice, I think one of the issues here that you are perhaps aware of is that there have been suggestions by other dental hygienists that "on the order of a dentist" should be taken out entirely and they should have an even more independent practice. So your point of view is different and interesting.

But in following along, would it not be that the college that would be set up here in fact would be dealing with many of those concerns around the independent practice that would be permitted here? I am trying to get the balance between where we say to you and your colleagues as professionals that we would recognize that you would not do those things for which you are not properly qualified or trained. While I do not understand all of the things that would be permitted under what is set out here, it seems to me that as we move into long-term care and we move into dealing with people in their homes, we need to develop greater flexibility, in a careful way.

Mr Beer: Why would you not see a dental hygienist being able to perform a number of those activities?

Dr Boksman: I can take that, if you will. I think the flexibility issue is extremely important. When we are dealing with patients who are possibly at risk, our concern is that we create legislation that protects our constituents from possible harm, and in this situation there is definitely a medical risk involved which the hygienist is not trained to diagnose.

Mr J. Wilson: Just to point out that we are sympathetic to your concerns about Bill 47, section 3, and the definition in the scope of practise and will undertake to try and straighten that out during the clause-by-clause proceedings.

But I am interested, I have had dental hygienists in my own riding of Simcoe West come and certainly give me the impression that they would like to be able to practice independently, for instance, in long-term care facilities. Is that, in your opinion, very much a minority group? I know yesterday we had the Ontario hygienists' association stress the team approach, so we kind of get conflicting views.

Mrs Paquette: It is a direct quote that I did state in the presentation, just in May 1991, and I do believe that I am --

Mr J. Wilson: Adequately expressing the majority of the members.

Mrs Paquette: Yes, with my colleagues.

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



The Chair: William Reid and Max Hanna. You have 10 minutes for your presentation. If you leave a few minutes at the end for questions from committee members, it would be appreciated.

Dr Reid: Before I start my presentation, I would like to mention that my colleague Max Hanna will not be speaking through the presentation but is willing to answer any questions after. Our philosophies are the same. We have gone through this, and although they are my words, we are on the same wavelength with this presentation.

My name is William Reid and I have been a dentist in east London for the past 25 years. My colleague Mr Max Hanna, a denture therapist, has been involved in dentistry for over 45 years and has practised in the same building as myself since 1975. We have collaborated during this period in providing partial dentures for the public as specified in the existing legislation and have similar feelings regarding the proposed new law. Mr Hanna also works with Dr Bruce Pellow, another dentist in the building, and Dr David Adachi in the village of Watford.

The new bill that allows denture therapists to provide partial dentures to the public independent of the dental profession is poor, retrogressive legislation. It is absolutely essential that the lawmakers and public understand that the ultimate success of a partial denture is dependent upon the status and health of the existing teeth and supporting structures, and conversely, the integrity of the teeth depends upon a well-designed and constructed partial denture appliance. Max Hanna surely wants his partial denture to satisfy his and the patient's expectations, and I certainly want the existing teeth to not be comprised by the denture that he places.

In short, all our training and experience tell us that to provide a proper partial denture service to our patients, certain basic biomechanical criteria must be satisfied. The training provided and the scope of practice allowed by law in denturism in no way enables the therapist or denturist to do this.

For example: It is stated in the proposed legislation that an assessment of the arch is all that is required. We fail to see how this serves the needs of the public. Remember, teeth are present here and a diagnosis with a periodontal examination using a perio probe, vitality tests, necessary radiographs, X-rays and other diagnostic measures must be taken. A denture therapist just does not have the diagnostic tools, information and training that is needed to make solid judgements as to the status of the teeth and the structures that will support the partial denture.

Second, the great majority of partial dentures require rest preparations and guiding planes to satisfy well-established design principles. A denture therapist, by law, cannot cut into teeth with rotary drills to provide these essential modifications. This fact alone should give the committee pause to re-evaluate the new legislation.

Third, a denture therapist, without a total diagnosis, is unable to provide legitimate treatment options to the patient. Just because there are spaces in the arch does not automatically mean a partial denture should be placed. A bridge or even no treatment at all may be the proper direction to pursue. Many times a choice of which way to go will be made by the patient depending on finances, age, time constraints, etc, and this is good, because he or she has been given all the information needed to make alternative choices. There is new legislation that is being considered by this government that will assure patients in all health fields of the right to be totally informed as to treatment. From our point of view, Bill 50 does not allow all patients to be fully informed as to treatment alternatives, and this is definitely at odds with the other legislation.

Mr Hanna and I have been working together within the existing law for the past 15 years. I recognize his fine technical abilities and the genuine goodwill he has with our patients, and he can count on my involvement to advise and prepare the mouths of his patients so he can do the things that he has been trained for and does best.

A typical patient who presents at his office might have an old, ill-fitting upper denture and a lower dentition that is compromised but, with treatment, salvageable. He would take preliminary impressions and refer the patient to me. Following a diagnosis, I would discuss the treatment plan, alternatives and prognosis with the patient, then proceed to do any necessary dental work required, such as extractions, cleaning, restorations and oral hygiene instruction.

Meanwhile, a design for the lower partial is done, and prior to sending the patient back to Mr Hanna for construction and fitting of the new full upper denture and lower partial denture, I would cut the necessary rest preparations, providing guiding planes and make any other adjustments to the teeth that are needed. After he delivers the dentures to the patient, I examine the finished appliance in the mouth. Mr Hanna will have the patient back for any adjustments needed, and we encourage the patient to return for dental checkups to help assure the longevity of the remaining teeth. This is a typical scenario. Rarely in all the years of practising together have we encountered a case that really did not require some input from myself.

We respectfully submit this presentation to the committee to show how this team approach in regard to the delivery of partial dentures serves and protects the patient and to show our concern that removing the dentist from the process, as proposed in Bill 50, would be an astonishing retrograde step in the provision of quality dental care.

Mr J. Wilson: I think you spell out very well what the denturists want under Bill 50. They certainly claim time and time again before the committee and made a very good presentation yesterday indicating that the dental profession has not been able to provide any proof of serious harm caused by them doing partial dentures on their own. I just want to give you the opportunity to comment on that.

Dr Reid: It would surprise me that the Ontario Dental Association could not make a presentation to that area. As far as harm is concerned, I really cannot understand how a denture therapist can really determine harm. It is not within their abilities to do so. Harm, with partial dentures -- supposedly an abutment tooth or a supporting tooth, when the denture is placed and the patient is happy -- is 10 millimetres. How do they know two years later, when it is eight millimetres, that it is eight millimetres? There is no way for them to even do that. They do not take X-rays. They do not make measurements. The harm may be there and not forthcoming for a while.

We know from the mechanics of partial denture therapy that there are certain criteria that have to be there to make a successful partial denture. When they say harm, it is not as if the mouth is going to blow up; it is the integrity of the teeth over the rest of that patient's lifetime. It would be sadly compromised.

I cannot comment on why the Ontario Dental Association has not presented anything. It may be that they do not want to take the low road and go that route, but I am sure there are instances, because we do see these instances. I know there have been presentations from private dentists to the ODA on harm that has been done.

Mr Winninger: I am told that only approximately 5% of an average dentist's work involves denture work. Do you agree with that estimate?

Dr Reid: I think that seems to be probably close to it, but maybe in my case a little more. I have been in practice a little longer.

Mr Winninger: So the suggestion that you as a profession might be just protecting your turf may be ill founded.

Dr Reid: I think it is ill founded, because we use a denture therapist. I do not covet his patients. I just want to make sure that his patients are happy and that the work is done properly.

Mr Beer: With the college that would be established by the denturists -- and it is a similar question to the previous group -- do you not believe that the College of Denturists would be able to set appropriate standards that the denturist, in receiving a patient, would be able to recognize, "I must refer this person to a dentist because of the nature of what I am going to be doing," or are you saying simply the difficulty is that they will not necessarily be able to recognize potential problems in a mouth?

Dr Reid: I am saying, categorically that they will not be able to. They are just not trained. My background and legal commitment is that -- as I say, I do resent the fact that if I place a partial denture and I have, let's say, not taken an X-ray and there is a cyst or something there in an abutment tooth, then I am legally responsible for that, and rightly so. I cannot see that the government could really put a poor denture therapist in jeopardy because he goes ahead and does something, the work fails and the patient wants to sue, because he just does not have the background. Max does not have the basic sciences. He does not have the medical science background that I do, and he is just unable. You would have to establish in the denture therapy course actual courses that would cover these things in the medical field. It is totally lacking now. It is not there.

The Chair: Thank you very much for your persentation. We appreciate your coming to address us. If over the course of time there is additional information that you think might be helpful, please feel free to communicate with us in writing.



The Chair: Dennis Lebert, you have 10 minutes for your presentation and if you would leave a few minutes for questions we would appreciate it.

Mr Lebert: Good morning. I am here today in regard to the proposed legislation that will make the prescription of a hearing aid a controlled act and what it will do to the hard-of-hearing in my area and other rural communities.

I have owned and operated the Chatham Audiometric Centre for the past five years and worked for three years with the previous owner, who had served the hearing-impaired since 1964. As a hearing instrument practitioner, I am a registered authorizer and vendor for the assistive devices program.

My office dispensed approximately 325 hearing aids in 1990, of which only approximately 43 were audiologists' prescriptions. In 1991 so far I have dispensed approximately 200 hearing aids, with 19 being audiologists' prescriptions.

These figures are fairly consistent with most rural offices. A large number of the hearing aids I authorize and dispense come from nursing homes and rest homes I service: Chatham eight, Blenheim two, Dresden two, Ridgetown one, Tilbury one, Wardsville two and Wallaceburg two, a total of 18. This service, audiometric evaluations, case histories, fittings, counselling and repairs on site, that I provide is very beneficial to hearing-impaired residents who in many cases are unable to be transported and usually have no possible way of going to an audiologist's clinic, except by ambulance, which would be very costly and would be a misuse of the emergency service ambulances provide.

Every time a hearing aid is authorized and dispensed by myself or any hearing instrument practitioner rather than going to an audiologist's clinic the taxpayers of Ontario save $100. With the 70,000 hearing aids that are dispensed in the province of Ontario, this figure cannot be taken lightly.

As you can see by the number of audiologists' prescriptions, a dispenser in many rural communities will not likely be able to operate if this bill becomes legislation. It will mean that the hearing-impaired consumers will have to go to larger cities to receive services.

The Association of Hearing Instrument Practitioners of Ontario had over 200 authorizers and dispensers in early 1989 and predicts that only approximately 130 will be left. Most of these 70 will be lost from the rural areas, where few audiologists exist.

How does this proposed legislation think that the current 259 audiologists will be able to give the thousands of hearing-impaired consumers the quality of care they are presently receiving with no complaints if these offices close? The rural areas in Ontario will be the hardest hit by this proposed legislation at a time when the population of 65 years and older is growing at three times the rate of the overall Canadian population. Fifty per cent to ninety per cent of these seniors suffer from some form of hearing loss.

In conclusion, this committee has the opportunity to stop this unnecessary legislation that will cause the hearing-impaired consumers in Ontario extra time, money and stress when all they want to do is obtain a hearing aid to improve the quality of life by hearing better, considering that there is no risk of harm and without waiting months for safe services that are available upon demand.

I have enclosed for your reading 11 letters I have received from different nursing homes and rest homes I do work for and, along with some clients, would have the same viewpoints as myself and my area. Thank you.

Mr Hope: Dennis, thanks for driving into London, as London is supposed to be the centre of southwestern Ontario. Dealing with the rural area, there are a couple of questions I have for you: First, where did you get your training from and from whom, and second do you serve any people under the age of 18?

Mr Lebert: My training was I attended the Sheridan College program which unfortunately has been disbanded due to some conflicts where different committees have felt that we should be doing just dispensing. So they did not want to teach testing and fitting, as I do now. When I received my training from Sheridan College I was taught by audiologists, doctors. They gave us the training, which also was that we had to have 1,500 hours of supervision, which I received from the gentleman I purchased the business from.

Your second question regarding children under the age of 18: I do the actual dispensing of the hearing aids for these children as long as they have been recommended by an audiologist and a family physician has given medical clearance for this work.

Mrs Cunningham: My question was in regard to the training too, because spokesmen for your group have been into my office to discuss it with me and from what I can understand, if the training does not change -- I am now talking about requirements -- and if it is not presented across the province so that there is accessibility, I am just wondering about the future of your work, if you would like to speak to that.

Mr Lebert: Luckily, with my age, I have been able to get into the business young enough. The problem we have as an association is that the average age of the authorizers and dispensers is 55 years old. These people cannot be replaced. So the thousands of people who are being taken care of by these elderly people -- watch how I say that -- will be lost. There is no one who is out there who will be able to replace these offices.

Because of the George Brown College program that we have been trying to get started, the major downfall is that they do not want us to be able to do the authorizing, so that there has been a great difference there. But these people will not be able to, as I say, in the rural areas, replace their offices because there is no one being trained at the present time.

Mr Beer: Has your organization had any discussion with the audiologists? Is there some compromise position? Are there some, in your view, legitimate concerns about how people might be treated? Is there any other place to go here, or do you think that it is simply a case that you should be allowed to dispense hearing aids to anyone who wants one?

Mr Lebert: I am not on the board of directors for the association, so I cannot answer if they have been meeting. It is my understanding they have. Their viewpoint, to the best of my understanding, is that the audiologists do not want us to do any type of hearing testing or prescribing of a hearing aid, which we do now.

The problem with that is when a person comes into my office with a hearing aid that is five or six years old that needs to be replaced, I have to do the hearing test presently to find out if he needs a stronger hearing aid, or which type of hearing aid needs to be replaced for this person.

The Chair: I have a request from the parliamentary assistant to clarify.

Mr Wessenger: I would just like to indicate that there is nothing in the legislation that will prevent the dispensing of hearing aids.

Mr Lebert: We will not be able to dispense the hearing aid if we do not have the opportunity to do the hearing test to find out what type of hearing aid is needed by that person.

Mr Wessenger: Perhaps I should also clarify there is also nothing in the act that will prevent doing the hearing tests.

Mr Lebert: With the prescription of a hearing aid?

Mr Wessenger: What would be prohibited would be the actual prescription. Of course the definition of prescription has not yet been determined, but that could be either on the order of, for instance, a physician, which could merely be a referral to you to say, "This person needs a hearing aid," and you could go ahead and still do it on the simple order of a physician that indicated the need by the patient.

Mr Lebert: How would a family doctor, or an ear, nose and throat doctor be able to give a prescription that says, "You need a hearing aid," if he does not have an audiogram or any case that says that the person has a hearing loss?

Mr Wessenger: My understanding is that there is going to be flexibility in the administration of this in that it will be up to the physician to make that determination of how specific he is going to be with respect to the question of prescription. I understand it can simply be an order that this person is suitable for obtaining a hearing aid, and it would be up to the medical practitioner to determine whether the situation was such that he felt that the testing was required by an audiologist. I would assume in certain instances, particularly in replacement of hearing aids and so forth, particularly for the elderly, it would be deemed not perhaps necessary to have those tests. I am just surmising here, but I would assume also in the case of young people, obviously those tests would be required.

Mr Lebert: With older people also, we have people who come into our office daily who say they have a hearing loss, "I need a hearing aid." We do a complete case history audiogram on the person, and they have no hearing loss at all. We have to just train the person for better listening techniques, rather than a hearing aid. That is where I see the problem without having an audiogram before the prescription of a hearing aid.

Mr J. Wilson: Madam Chairman, may I just interject a couple of points?

The Chair: We are out of time on this presentation. What you can do is make note of your question, and at the appropriate time place it on the record with the parliamentary assistant.

Thank you for your presentation this morning. We appreciate your appearing before us.

As members know, there will be additional opportunity to discuss these matters. If you have questions that you would like responded to from the ministry, there is an opportunity to do that, or you can place it in written fashion as well.



The Chair: Louise Carroll, you have 10 minutes for your presentation.

Ms Carroll: Hello. My name is Louise Carroll. I am a consumer of health care in Ontario. What I want to say first is that I strongly support the overall intent of Bill 43 and its companion legislation, Bill 56. Midwives have a crucial role to play in the evolution of our health care system in Ontario, and I am encouraged to see that midwifery is finally being given the autonomy and recognition it deserves as a profession.

The implementation of this legislation is personally very important to me. As you can see, I am several months pregnant. London has quality obstetrical services, and there are some wonderful doctors and nurses. Several of my friends during childbirth made a connection with hospital staff on duty. However, the experience of one close friend in particular prompted me to seek alternative care for the birth of my daughter. When my friend recalled her birth story, she said she had felt very alone, uninformed of her progress and felt that she had no active part in decision-making. She was automatically placed into a position where she felt unsupported and powerless to ask for what she wanted.

I chose to increase my chances of a healthy, supported, non-medicated birth by working with a midwife in a hospital. With the midwife, I felt supported in my decisions regarding the birth and felt more comfortable knowing how long I could labour at home before going to the hospital. Even then, because of the lack of legislation regarding midwifery, there were still uncomfortable moments with hospital staff. After the midwife had been involved with so much of the labour, up until reaching the hospital and at the hospital, I really would have been happier if she had been allowed to catch and if that legislation had been in place allowing her to do that.

It is important that women in Ontario have more personal choice available to them in childbirth. Healthier babies and family relationships may result when a woman can give birth with only the people she chooses and knows taking care of her. More specifically, with regard to Bills 43 and 56, I would support any necessary changes which would allow midwives to be primary care givers. These changes would include, but not be limited to, prenatal blood screening, heel pricks, insertion of an intravenous catheter for purposes of rehydration and access to a limited list of drugs for purposes of dispensing.

I would support the timely establishment of autonomous, freestanding birth centres as an obvious way to implement and support this legislation. Midwives need a neutral ground where they can practise, and women and their families need a place where they can have more personal care and choice. An autonomous birth centre would bring about a healthy comparison to the conventional health care system and initiate change within the system more quickly. I would support informed choice, where all health care professionals have a mandate to inform women about their choices, risks and options in child care. I would support holistic midwifery training, where midwives are educated to be familiar with and able to direct clients, when appropriate, to reflexologists, chiropractors, nutritionists, homeopaths, doctors, obstetricians and other health care professionals.

I would support the legislation of homeopathy as a useful profession and model of care. Homeopathy is established and respected in many other countries. As more of the general public becomes aware of the practice and use of homeopathy, it would seem prudent to establish access in a responsible way.

I would support continuity of care within the health system. If a woman has chosen to work with a midwife, in the event that she is transported to hospital, I would recommend that the midwife remain the primary care giver until such time as it is determined that the primary care giver should be an obstetrician. The midwife must remain as a primary support person and, if there are no further complications, resume post-natal care. Finally, I fully support the intent of Bills 43 and 56, with the changes and concerns I have mentioned.

I have a question for the general committee of course: If the midwifery bill has its final reading this fall, can I expect a midwife to catch me in a hospital in Ontario by January? That is my deadline.

The Chair: Thank you very much for your presentation. I have a question from Mr Hope but, Mr Wessenger, would you like to answer the question first?

Mr Hope: I was going to pose that question.

The Chair: Is that your question?

Mr Hope: Yes.

The question and concern I have, in listening to all the presentations on midwifery and looking at her question, is by January and before January could she have the midwife present? It is subject to the hospital's discretionary power, I guess, whether it wants to let a midwife in. Could you just elaborate a little more so that it is clear to me and also to the young lady making the presentation?

Mr Wessenger: I think I will refer that to ministry staff.

Mr Burrows: At the present time midwifery is not a recognized, self-governing profession, so any accommodation the system has for midwives is exactly that. The midwifery task force concluded, and it is on the public record, that presently midwives find themselves operating outside the system and technically operating in an illegal atmosphere. The current thrust of the interim regulatory body being approved by government and this legislation is to rectify that situation. In fact, we recently had a coroner's inquest in Toronto that made very strong recommendations about the need to regulate midwives for the protection of the public. That being the case, the situation that would prevail in January, if this legislation is not passed, would be the same at present: whatever accommodation could be made between those operating outside the system and those who legally operate within the system.

Ms Carroll: However, if the legislation is passed, would that have an effect on something being able to be worked out in January other than what is currently going on, which is an arrangement usually between your own doctor and a midwife?

Mr Burrows: Passage is one thing; proclamation is another. We will not be able to proclaim this legislation immediately upon passage for the simple reason that we have to write regulations under 22 acts and they will need to be vetted in a transparent way. Second, the system has to make whatever changes are necessary to accommodate this, and there are a number of important policy decisions that have yet to be taken, such as practice sites, methods of remuneration, etc.


Ms Carroll: How do you feel about the practice site of a freestanding birth centre?

The Chair: That is a question for the parliamentary assistant, not for ministry staff. We will put that to the parliamentary assistant, if you wish to answer.

Mr Wessenger: I think it is a very interesting concept. It is really just a question of determining what the appropriate location is and so forth.

Ms Carroll: Do you feel it would implement the legislation faster and allow it to be more real, more practical and more usable by consumers?

Mr Wessenger: I am only speaking personally in this case. I think it is a good concept and certainly I would like to see it implemented in some manner.

Mr Beer: Madam Chair, as you know, the Independent Health Facilities Act, which the previous government brought in, was to allow for the development of proposals for a variety of services, and undoubtedly that will be one of the proposals that would be coming forward.

The question I want to ask you really does deal with what you might face in January or even after the legislation, the regulations and so on are there. What has been your experience, in working with the health care professionals who are there, doctors and nurses, around your having a midwife? Clearly we know you can have legislation and regulations, but we are working on an attitude change. What is your sense of where those other professions are in acceptance of midwifery?

Ms Carroll: My daughter is now a year and a half old. Even in the last year and a half things have started to change, and I can only speak for the London area. Things have changed a little bit in some areas. I cannot say there have been major changes. Even if this legislation comes through, it is going to depend on how nurses and doctors react to this. Some people are reacting and looking forward to this as being an evolution, something that really has to come to truly give meaningful, personal care, and other people are feeling threatened by it. That is my impression.

The Chair: Perhaps I could be helpful for members of the committee, as I have some information regarding your question about January. The interim council has also determined that all midwives who are presently practising in Ontario would require educational upgrading before they would be able to practise as primary care givers within the health system in Ontario. It is contemplated that it would take approximately two years before that could happen, and that would allow the system to make the adjustments necessary and allow for the implementation of this legislation.

The answer to you is no, that would not be possible this coming January even if this legislation were passed and proclaimed, because of the educational requirements as recommended by the interim council. However, over the course of the next little while, provided this legislation is passed and the education program put in place, you will see the gradual implementation through hospitals as well as ultimately independent birthing centres, I believe. That is contemplated by government policy, and I have heard no change in that policy.

Ms Carroll: If you choose to have a midwife attend your birth, I guess it is still going to come down to your having to connect either with a family physician or an obstetrician who is willing to support that choice and allow you to do that. That is probably going to continue for two or three years.

The Chair: That is correct.

Ms Carroll: It is disheartening for me in one sense, because even when I had a midwife with a family doctor who was open to having that, but still wanting to maintain control of the catch, the last 20 minutes before he arrived -- that is one of the concessions you make when you do that. It is funny; it is still even being in that hospital setting and even just trying to work. If I am not able to have a midwife with me this time, at least I know I am going to have a patient advocate with me, someone who can handle the politics, and I can just focus on the labour and being with my family and will not have to deal with some of the people who are wanting me to be -- in my own personal experience, for example, I was on a birthing stool, I was ready to push and things were going well and the nurses were so concerned that I should be up on the bed and ready before the doctor got there. But when my doctor arrived he just said: "Great, fine, that's good. Things are going well. Let's go with it." It is the perception of what people should be doing, and really the focus should be on working with that person and supporting her in labour and helping her to have a really joyous birth and bringing that back. I think that is what is really important.

The Chair: Thank you very much for your presentation before the committee. If there is any additional information that you think would be helpful to the committee, please feel free to submit it in writing at any time.

Ms Carroll: Thank you very much.


The Chair: Welcome, Dr Gus Scheid. You have 10 minutes for your presentation.

Dr Scheid: My name is Dr Gus Scheid and I am chief psychologist at St Thomas Psychiatric Hospital in St Thomas. First, I thank the committee for the opportunity to present to it.

My general reaction to the proposed legislation is an extremely positive one. It renders the regulated professions accountable to the public, protects the Ontario citizen from unqualified practitioners, provides a spectrum of informed choices for those seeking health care and provides a quality assurance mechanism for professional clinicians in various disciplines. It has been long in coming and should be most welcome by the health professionals and consumers in Ontario.

This having been said, I have four points to make with some problems I have specific to Bill 63, the regulation of the profession of psychology. First, provincial regulation by law is not new to the profession of psychology; 31 years ago the Psychologists Registration Act of 1960 restricted the use of the title "psychologist" to those registered under the act and set up a governing body, the Ontario Board of Examiners in Psychology, to determine registration requirements and protect the public by enforcing standards and quality assurance for those in the profession.

The same act prohibits anyone, except those who are registered, from holding himself or herself "out to the public by any title, designation or description incorporating the words `psychological,' `psychologist' or `psychology.'" The act simply protects these titles without in any way interfering with other disciplines in their offering of therapy or counselling.

The act currently before Parliament, on the other hand, significantly erodes the protection which the 1960 legislation provided to the Ontario public by restricting only the title "psychologist" and not restricting the use of the related words "psychological" and "psychology." Thus, anyone at all with any or no qualifications can represent himself or herself as a psychological consultant or as having a practice in psychology or in any of the countless ways in which words signifying something similar can be combined.

Without the least fear of error, I maintain that the general public will never be sophisticated enough to distinguish between registered, qualified, controlled and accountable members of the college and others who use such appellations of themselves. I believe the government has an obligation to protect the public by framing the language of the RHPA, and specifically Bill 63, to protect the words "psychology" and "psychological" and their variations or abbreviations. This protection can be provided without penalizing any other professional group.

Second, in subsection 15(1) of Bill 63, the title of "psychologist" is restricted to members of the new college for those providing "health care." By regulating only those psychologists who provide health care, the present legislation removes a very large number of psychologists who were previously regulated under the 1960 legislation and absolves them from any regulatory control at all. Once again, I believe this is an enormous disservice to the public. When I seek to employ a lawyer, I expect him or her to be fully registered with and regulated by the bar, whether my need for a lawyer is in regard to real estate, a divorce action, a civil suit or a criminal defence on a murder charge. Why should the public expect any less protection in the case of a psychologist? Is it any less important that a psychologist in an educational, industrial or organizational setting be qualified, registered and regulated than a psychologist in a health care setting?

"Health care" can, and likely would be, interpreted very strictly and conservatively. I would strongly suggest that the limitation created by the "health care" words in subsection 15(1) of Bill 63 be removed by simply removing the words from that part of the act, thereby regulating all psychologists and increasing protection of the consumer.

Third, psychologists are one of the five groups accorded the licensed act of diagnosis. I have been given to understand that there is a lobby against psychologists being licensed to diagnose. Given its importance, I cannot conceive of diagnosis itself ceasing to be a licensed act. Given that, it seems that psychologists should remain one of those groups licensed to diagnose for the following reasons.


1. Psychologists receive formal training in diagnostic assessment and indeed possess a psychometric technology available to no other profession.

2. Many psychologists have practices entirely devoted to diagnosis.

3. Many multidisciplinary teams, such as those in our hospital, frequently look to psychology for their diagnosis.

4. Psychologists being licensed to diagnose in no way threatens the work of unregulated professionals.

Finally, there is the issue of entry level for registration with the College of Psychologists of Ontario created by the RHPA. I realize there is a lobby to weaken the registration requirements from those which the Ontario Board of Examiners in Psychology currently require.

The lobby to diminish registration requirements began in the early 1980s when Mr Schwartz and his committee were giving birth to the current proposed legislation. After careful examination, the committee elected to leave the requirements as they are today. I applaud this decision and think any other would further erode public protection and quality control. Consider the following.

All across North America most jurisdictions require the doctorate for registration in psychology. Those few that do not are moving in that direction. What would prompt Ontario to regress to lesser standards?

Would the Legislature entertain lowering entry level requirements for dentists or for surgeons? If not, what is the difference?

In the early 1980s, an analysis was conducted on the examination requirements for registration as a psychologist. It was concluded that it was inconceivable to allow people to sit for these examinations pre-doctorally.

Many of those who are currently lobbying for a reduced requirement for registration as a psychologist have their backgrounds in areas totally other than psychology.

Keeping the current registration requirements does not interfere with any group's practice of its profession. They simply cannot be registered as psychologists.

Finally, I believe the entry level issue should not even be debated in this context. It is outside the scope of this legislation, as I understand the act. The college established by the act, as with other regulated profession, should determine the issue for the profession.

I thank you for your time.

Mr J. Wilson: Thank you for your presentation. You made your points very clear. I am going to ask you anyway, under the area of title protection, your first point and fourth point, we have had evidence before this committee that a number of the non-doctoral practitioners, many unregulated psychologists, for a lack of any other terminology in this committee, who seldom ever see a PhD, are practising, for instance, in northern Ontario. They are very much worried that their practice would be threatened. I am worried in that context.

Although you make it clear that you do not feel this is part of the bill, I think it is in the context that if we continue to extend title protection to the terms "psychological" and "psychologist" and "psychology," the three terms, and if the agreement that has been worked out, the task force that has been established to work together over the next 18 months between the non-doctorals and the members of the college, were to fall apart in some way and an agreement is not reached, I am worried that by giving the full title protection we would somehow be impeding those non-doctoral practitioners. Do you want to comment on that?

Dr Scheid: I do not think the fact that there are some communities in outlying areas which have a difficult time attracting doctoral-level people is any reason to modify legislation that applies across the province when we are trying to achieve certain standards. I think that is an exception. I think it is great they are there. When their absence would mean no resources at all, I think it is great they are there. Also, I do not think it impedes anybody's practice. Any member of this committee could rent a room in this hotel and hang a shingle out saying "Psychotherapist" or "Counsellor" or "Shrink" or anything you want to call yourself, except you cannot call yourself a psychologist. I think that is fair enough. I think you can practise your profession and do the kind of work you are trained to do without using that title if you are not entitled to or qualified to have that title.

Ms Haeck: Dr Scheid, I am sorry that I was not here for all of your presentation, but I did notice something right when I came in. As a politician, I have come to know very quickly that perception is really all of reality. I make a large assumption, and that is that your views are your own and not those of the Ministry of Health, whose letterhead you have used.

Dr Scheid: That probably is a misjudgment on my part. What happened was our assistant administrator forwarded a memo from Janice Buchanan saying that invitation was issued. I gave this to my secretary to type, I am afraid, without checking. I apologize for that.

Ms Haeck: I understand how these things do work, but I do want to give you the opportunity of clarifying that.

Dr Scheid: This is my personal position as a member of the psychological profession.

Ms Haeck: Okay, very good. Thank you very much.

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


The Chair: Mr David Breznik, welcome to the standing committee on social development. You have 10 minutes for your presentation. We ask if you would leave a few minutes at the end for questions from committee members.

Mr Breznik: Ten minutes is not long for all I want to say, but I am going to do my best with it. I wish to respond to Bill 56, An Act respecting the regulation of the Profession of Midwifery. I come before you on two points: (1) having a daughter who wants to get into this and (2) my wife and I would like to have a midwife for our next birth.

Throughout our lives we are confronted with situations and decisions relating to authority. Each one of us here is under an authority. Authority provides for us an umbrella of protections, and our character is shown through our response to these authorities. This presentation is not a condemnation of the authority of the proposed college, but it is an appeal to the authorities responsible for the design of Bill 56.

Realizing there are instances where help may be required, we believe birth should be viewed as a natural function and not a medical procedure. Birth will occur whether or not medical training and facilities are available.

We are concerned that this bill will deprive women of choice in selecting a midwife, discriminate against young married women who may choose to enter the workforce as a midwife, hinder women from making their own decisions on what is happening within and with their bodies and attract the wrong candidates for the field of midwifery.

The proposed act states in section 15 that no one, unless a member of the proposed college, practise as a midwife in Ontario. I see no provision for acceptance of licences or accreditation from other licensing bodies from within this country or from without.

I recently read an account of a woman whose mother noticed that she was not responding as a normal child when she was born. Her mother took her to many doctors and specialists. Many tests were done and they all said basically the same thing, that she would have to be institutionalized for the rest of her life. Until the age of 11 she lived five days a week in institutions where she was under treatment in various programs, coming home on weekends.

When she was 11 years of age her father received a transfer to the company's European branch. They took their daughter with them. They brought her to a specialist in Europe who examined her and gave her a diagnosis and prescribed treatment. Within 10 days she was responding as a normal child. They later returned to North America and she went on to graduate from college at the top of the dean's honour list. Just shortly after graduation she went by the institution where she had been and visited some of the children she had been in with. They were still there.

The medical profession in this case was limited by its training. Please, I appeal to you, please try and avoid this pitfall. Do not have a narrow view. Allow for acceptance of other accreditations. Make provisions for the training of midwives from other than the proposed college. Please do not deny choice to women who wish the services of a midwife who is accredited elsewhere, nor to those women who wish to receive their training, for whatever reason, from a course other than that of the proposed college.

In preparing for this presentation, I held conversations with many practising midwives throughout this province. Some have been on committees in preparation for this legislation. I have been informed this course will be from three to four years, although no one could tell me for sure. I submit that anything over one year will place hardships on those women wishing to become midwives and will especially discriminate against young married women with young families wishing to enter the workforce. A young married woman with small children, living some distance from the proposed college, as is very likely in this province, would have to leave her young family for a semester at a time. This would put undue hardship on both the women and their families, and many would not be able to make this decision.

At one time our doctors, lawyers and many other professionals were trained through apprenticeship. I am personally in favour of apprenticeship, as it tends to reduce the amount of peripherals and also brings a better understanding.

Years back I was employed by Ontario Hydro in the nuclear power division. When I was hired I was sent to their training centre. They taught a lot. However, it meant little as I had never been in a nuclear plant and I could not relate to the systems and devices they were discussing. However, after a few months working in the plant I wished I could have had a repeat of that training as now I saw the systems and devices and I could relate and ask questions.

Apprenticeship: There are few portions of this province that do not have a midwife whom someone could apprentice under. They could train under a midwife and return to a training facility after so many births for a two- or three-week course to ask questions, to learn different procedures and methods and to receive advice.

An apprenticeship based on perhaps 75 assists and maybe 25 births, which will include several months of classroom training that will be broken out over a period of time that would reduce the hardship and stress, would go a long way to eliminate discrimination against young mothers with children and those living in remote areas of the province. It would also reduce costs by eliminating courses not essential to the practice of midwifery.


When a family expecting a child decides to have a home birth, they make this choice for one or all of many reasons, one of which is the ability of the family to make their own decisions. When our children were born, I was with my wife for most of the time in the hospital. We cannot recall anyone, doctors, nurses or even orderlies, asking us if we would like this procedure, that procedure, this position or that test, or even discussing anything with us. We were not consulted or asked; things were just done. We had no say and we were not expected to have a say. After our last child was born, my wife said never again would she allow that to happen to her. We then decided we would have the next child at home and my wife and I would make the decisions.

We have a concern that if this proposed college is going to be the only place to allow membership to practise as a midwife, and it has a long-drawn-out course, it will eventually support birthing hospitals and birthing homes. It will affect the private home birth by bringing the atmosphere of a hospital-like setting with all of its businesslike starkness to the home, and the decisions of the women as to what is happening to them will take a back seat to procedure and efficiency.

Midwifery is already recognized and legitimated by those who are using the service. When, through this legislation, it becomes officially recognized and financially backed by the guaranteed payments of OHIP, we have a concern over reasons why applications will be made to this course. We have a concern that whereas now those who are engaged in midwifery are doing so because they enjoy doing this, because they have found they have natural abilities and people skills, once this is a degree program it will attract those who want a career and not provide a service. We have a strong concern that those with the natural skills but not the academic ability will not be able to gain entrance. Some who are accepted may excel in midwifery courses but fail in peripheral courses which will deny them becoming members of this proposed college.

I see it as like a car mechanic, somebody who is really good under the hood of a car and makes that car purr, who is told he has to go for three or four years' training at a college. When he gets there, he passes all the mechanics courses but fails the rest and is denied the licence to be a mechanic. We will have licensed people with degrees and certificates, but will we have people with understanding, with wisdom, with knowledge? Will we have people with character who are diligent and dependable, who have the character of being patient and responsible? Will we have people who are sensitive and gentle, who are compassionate? Or will we have people with a good business and a career?

This act, as we have seen it, does not address what will happen to those who are already practising midwives or those who are currently taking their training out of province. It does not address the length of time involved or the courses to be taught. It does not address any provision for religious conviction. In my discussions with midwives throughout the province, I had several mention that they would flatly refuse to take some of the courses that have been proposed, such as psychology or relaxation methods based on eastern religious techniques.

To summarize, I appeal to you to recommend that we do not limit ourselves and place obstacles in front of women by allowing for only one body that can train midwives. I appeal to you to emphasize apprenticeship and thereby remove a discrimination against young married women. I also appeal that you recommend that members of the board of this proposed college not be comprised wholly of doctors and nurses but also be made up of members of the interested public and that there is an equal representation of midwives from around the province.

While I was preparing this and was talking to various people, one woman did send me a letter which so came close to what my wife and I believe I included it with this. Thank you.

The Chair: All of the members of the committee have received your written presentation, including the letter you referred to.

Ms Haeck: Thank you very much, Mr Breznik. It is always good to hear from the consumers of these services. You make some very good points. At this time, just for clarification, I am going to direct my question to the PA and ministry staff. It is my understanding that in the concept of the whole legislative package the colleges would be doing the regulation of who in fact would be forming their membership. The quality assurance portion of Mr Breznik's recommendations would also fall within partial regulation. They would be half public and half members of the college. Can you, just for clarification, comment on those points?

Mr Wessenger: That is correct. It will be the governing body that will be determining these matters. Of course we have not yet set down the whole question of what standards will be applicable, both to existing midwives and to new entrants into the profession, but I think one thing we have to remember is that there is quite an extension of authority being granted to midwives. They are moving from working in a supervised setting to, in effect, having an independent role. Obviously we have to protect the public in this regard.

Mr Beer: My question relates to your concerns about how midwives are going to be trained and how they are going to be licensed. If you look at the development of this in a political sense, I think there has been a broad spectrum of agreement right from 1987 when Murray Elston, who I think was then the minister, announced there would be regulation of midwifery through the Independent Health Facilities Act which would allow for independent birthing centres, and the present government that has continued to support the development of midwifery. Do you not believe, within that, there still needs to be, for the protection of the public, protection of standards? As has been stated, the majority of members of that college would be midwives along with people from the public. Could we place our faith and our trust in them to establish the kinds of standards that would both protect the public and meet many of the concerns you have?

Mr Breznik: I would hope a lot of the board would be made up of midwives but I have a concern that a lot of those midwives may have graduated from nursing school and they would have a different outlook towards it than somebody who just went in to midwifery. The question that comes to me from that is, if my daughter took training in the United States, would she then be accepted here as a midwife?

Mr Beer: But I think one of the things the college would be doing is looking at programs, how they would accredit programs from different countries, how they would deal with those midwives who are already here who could perhaps be accepted because of the training. Those are issues that, in effect, midwives would be determining and dealing with. I would think they are the appropriate people we would be turning to for that kind of decision.

The Chair: This is the first time that we have had a consumer of a service ask a question regarding who makes the decisions in a self-regulating regime. Just for your information, and for any of those that are interested in this point, in a self-regulating framework it is up to the profession, through the professional colleges as differentiated from the educational college or university, who would establish entry to practise for the profession as well as standards of practice, quality assurance programs, educational requirements. The membership of that college will be determined by the legislation. But the legislators, including the government, will not be making those decisions. This confers self-regulatory and self-governing status on the professions that meet the criteria for that status.

Mr Breznik: So who sets up the board for that?

The Chair: The board is established in accordance with the legislation that is proposed and the professionals themselves elect members to that council. The government appoints individuals who are the public representatives on that council and, just for your information, and I am sure the midwifery task force would be happy to clarify this for you, there has been an interim council set in place, because this is a new profession and it has been ongoing for quite some time now, to allow for the implementation of a new profession in Ontario. I am sure the ministry staff, parliamentary assistant, and others would be happy to answer any of the technical questions as to how this will work.

Thank you very much for your presentation today. If there is any additional information you feel would be helpful to the committee, you can at any time communicate with us in writing, and if you have any questions, I would encourage you to discuss them with the parliamentary assistant or with Mr Burroughs.



The Chair: Next is A. Dale Vellet.

Dr Vellet: My name is Dr Vellet. I am from University Hospital. I am the director of body magnetic resonance imaging at the hospital and this representation is really on behalf of the technologists who run our magnetic resonance imaging unit. By necessity, almost all of the technologists are recruited from either nuclear medicine specialties or radiation technology specialties. We have no formal specialization of radiation technologists per se in magnetic resonance imaging, the problem being that once they are seconded to operate and run a magnetic resonance scanner, they stand a real risk of losing their accreditation with their original specialties such as nuclear medicine or radiation technology. So this presentation is really fairly simple. That is, is there no way of one circumventing this possible loss of accreditation? Is there no mechanism we can put in place that will allow them to retain their accreditation but, at the same time, work in magnetic resonance imaging?

Mr Wessenger: I will refer that to ministry staff.

Mr Burrows: This legislation would permit such things as stratified registers within the colleges. For example, if they wished to categorize a certain group of practitioners who had expertise in a certain area, that is allowable under this legislation. There is nothing preventing it. The standards that would apply both for entry and for continuing competence and quality assurance would again be decided by the governing body, the college. So one would expect this issue would be considered by the relevant college or colleges at the time of developing the regulations for entry to practise and for the quality assurance program.

I would also indicate that the Ministry of Health is aware of this particular issue and we have had discussions with some of the various associations who are represented in this. We would not see this as an insurmountable problem. Hopefully the system will accommodate that, because it is certainly not the intention of the ministry, or I think anyone affected in this, to eliminate or prohibit in any way people from maintaining their competence.

Dr Vellet: Is there any formal body one should then make a formal representation to, or should one leave this to the mechanism?

Mr Burrows: I would suggest that you continue to stay in contact with my branch and we will make sure that you talk to the appropriate people. I will give you a card.

Dr Vellet: Good. Thanks very much. That is all I have.

The Chair: Thank you very much for your presentation. If there is any additional information at any time, please feel free to communicate with the committee via the clerk.


The Chair: I call next Jerry Banks.

Mr Banks: Thank you. I am nervous.

The Chair: Do not be nervous.

Mr Banks: I could stand up in front of 2,000 people with a guitar on my shoulder and sing for four hours. To talk to you for five minutes, this could be a problem.

The Chair: It is not a problem. Would everyone please smile so -- there you go. All right, Mr Banks, just relax.

Mr Banks: My name is Jerry Banks and I have just driven 120 miles to express my concerns about Bills 43 and 57. I am a retired person, two months, and I am disgruntled with the way you are proposing to spend my health care dollars. If these bills pass as they are presented, the nursing care that I will receive will be almost non-existent, the way I interpret it. This is me; I am not a doctor, I am not a nurse, I am nothing, okay? I have worked at several jobs through my life. I want you to understand that my education is only what we called the senior matriculation. I do not know what you call it now.

Nurses are capable of performing approximately 60% of the activities of a physician, at a considerably lower rate of pay. They should not be restricted in the activities for which they are trained and they do now. The recent well-deserved pay increase should reflect our endorsement of their professional judgements. Nurses need to be given more freedom to counsel, teach and promote the best health care for their patients.

A nurse uses independent assessment of her needs, formulates a blueprint for care, carries out that plan and then evaluates the successfulness of the strategy. The nurse is my advocate when I do not hear or understand the physician; and believe me, I am deaf. His language is not that of the general public and very often needs translation. It is the nurse who is the front-line contact for me, the public, and needs to have the freedom to assess, to start treatment, counsel and educate as necessary without having to wait for the arrival of a physician from his office or you know where, a golf course or boat or up in the operating room delivering babies or whatever he is doing. Thus I feel the controlled act number 1 should definitely be included in the responsibilities of nursing.

The standing committee hearings are being held in major centres where teaching hospitals are found. Not one outlying area was selected for an area presentation. It is in these areas where the nurses need to nurse. Previously a large number of activities were deemed by physicians to be in their realm of practice. These duties were delegated to a nurse with additional training. However, the responsibility for conducting these acts was offered to the College of Nurses, which accepted the responsibility. Therefore, these delegated medical acts now become added nursing skills, entirely under the umbrella of nursing and the sphere of nursing practice. These skills may be performed by nurses with medicine's blessing. Now the government is opting to reverse this tried and true progression of health care.

Nursing should definitely be encouraged to apply and order forms of energy, as in controlled act number 7. The nurse applies and did apply the cardiac monitor to my chest and has the expertise to read the tracings and act upon the irregularities. It is the nurse who suctions a choking patient whether it be an adult or child. Waiting until the situation becomes an emergency is not good enough. Give nurses the freedom to exercise judgement and act responsibly as they are trained.

With regard to controlled act number 8, nurses are always in charge of medicine rooms and carts. I have seen the keys around their necks and so have you. If you have ever been in the hospital, you have all seen it. The nurse at the summer camp my grandchildren attended was the one who dispensed the hay fever decongestants and pain medicines.

Many areas of the province, including my own of Grey-Bruce, are not serviced by university-based hospitals where there is an abundance of interns and clerks of many health professions at the ready for 24-hour coverage. Nurses give care on a 24-hour basis. Many other professions that would be regulated under this act have bankers' hours, from nine to five Monday to Friday. Who will give the care on the weekends and the afternoon shifts and night shifts?

Nurses view the patient as a whole human being, physically, mentally and spiritually. Their care is not fragmented. Rather they are the ones who co-ordinate care and should not be simply assigned to follow orders. I feel controlled acts 1, 7, 8 and 11 should be deemed in the scope of the nursing practice and the rider, "on the order of a qualified person" should be removed from acts 2, 5 and 6. In addition, other areas of concern that need to be performed by nursing with additional training or in the areas not really serviced by a physician should be permitted at the discretion of the college of nurses. After all, if the college of nurses is being set up under this legislation, the college should be the evaluator of the controlled acts that its members are trained and competent to perform.

I trust these points of concern may be addressed and I thank you for allowing me to speak. I want to add a footnote, ladies and gentlemen. These are my concerns. Whether I am right or whether I am wrong, these are mine. If I interpreted some part of the act wrong it is because I did not have much guidance. I have talked to a few nurses, a few physicians, a couple of surgeons and I thought I had better do something. I have worked 18 hours a day all my life and now I am not doing anything, so I thought I would do something. Thank you very much.

The Chair: Mr Banks, thank you very much for an excellent and thoughtful presentation. The committee has been very keen to hear from consumers of health services and I know your presentation has been well received because there are a couple people who would like to ask you some questions. The other thing I think I can say on behalf of all the committee members is you did not look a bit nervous.

Mr J. Wilson: Mr Banks, you made a very good presentation. A number of the points you have made have been expressed by nurses themselves and certainly the government has made it clear and the opposition parties made it clear that it really is not the intent of the legislation to narrow the scope of practice of nurses and we are all going to work together in a non-partisan fashion to try and bring in amendments that will loosen it up.

Mr Banks: I am sure you will. I was an orderly for a while in my working years. I did not want to be, but I was. I have to say that something like this was a long time coming. Nobody has looked at this for I am guessing 20 years or more, probably before my grandchildren were even born. Somebody told me this has been on the table for about eight years. I know my government now, you people, will not let it go much longer. I have full confidence that you are going to look after this and get the show on the road.

Mr J. Wilson: I should ask what your definition of "my government" is.

Mr Banks: My government is everybody who sits in Queen's Park who represents Jerry Banks the taxpayer.

The Chair: Mr Banks, just a minute. Before you leave, I have a comment from the parliamentary assistant.

Mr Wessenger: Mr Banks, I would like to thank you for your presentation. In fact we think this legislation will give the nurses much more power. First of all, they can act in emergency situations. Second, there is provision for delegation to nurses. Third, when you bring out this question on the order of a qualified person, the College of Nurses of Ontario itself can set up a nurse as a qualified person. I know you did not understand that, but it really is a very much expanded role. This is quite unusual in the sense that the college of nurses itself can expand the role nurses can play, and the thought is that as nurses get special qualifications they can assume more and more responsibility. We have thought of that and we are working on it.


Mr Banks: Oh, great. That relieves me some.

Mr Wessenger: I really appreciate the spirit of what you presented today. Thank you.

The Chair: I have one more question for you from Ms Haeck. There is just one minute.

Ms Haeck: I appreciate all your comments and I will not repeat exactly what Mr Wessenger put forward. Having worked in a hospital you are probably aware that the hospital practice usually contains standing orders and that nurses and a lot of the hospital staff function under those. In emergency situations they deal with that situation as it arises. Are you aware of those situations?

Mr Banks: No. You mean I do not have to lie there and choke till the doctor comes in from the golf course?

Ms Haeck: Not at all. Part of the whole issue of standing orders is that if these situations do arise, if an emergency room doctor or your own doctor is not there, they are empowered to carry out the proper practice. How is that?

Mr Banks: That sounds better.

The Chair: Thank you for your presentation. I would like to ask a question. Was the experience as bad as you expected?

Mr Banks: No, it is not that bad, but I would sooner sing it.


The Chair: Tom Hebert, come forward. Welcome to the committee.

Mr Hebert: Thank you. I want to address the impact of this legislation on the practice of orderlies within the province of Ontario. I work in a hospital in Windsor, the Metropolitan General Hospital. I have been an orderly there for 22 years. As far as I know, orderlies at least within the city of Windsor and throughout southwestern Ontario have been in existence and performing the same acts I do now for at least 56 years, and possibly prior to that. I do not believe that orderlies are limited to southwestern Ontario though. I believe there are numbers of them throughout the province. My best estimate, although it is only an estimate, is that there are approximately 1,000 in Ontario.

My concern is with the prohibited acts. As they affect orderlies, they would involve urinary catheterization, enemas and actions surrounding those two basic functions. With urinary catheterizations, you have as ancillary to that irrigations of the bladder, both continuous and manual irrigations. With enemas, from time to time you have the need for disimpaction as well. Orderlies generally also give suppositories and perform tasks such as that. As I say, those are the two primary areas I am concerned about.

What has developed over a number of years is a delegation by registered nurses and doctors of these functions to orderlies because of the female-dominated nature of the nursing profession. I am sure everyone is aware of the discomfort many female patients will express or have expressed in the past about the lack of ability to go to a female doctor for some of the procedures because they are of an intimate nature. These particular procedures are of an intimate nature for males, and it has been felt for all this time that most men are more comfortable if a male performs them. That was the origin, I believe, of the delegation.

The skills are acquired through training by registered nurses or doctors. It is basically on-the-job training in a clinical skill and that is monitored. As you are working, the results of the care and treatment are being continually monitored because it is within the health care setting. As I say, the emphasis is on the clinical skills. Once a procedure is explained, developed and practised, the expertise that is necessary for the protection of the public is there. Of course you do not want an independent practice outside of the health care setting because clearly, from everybody's point of view, that would be inappropriate; but within a health care setting, by delegation or by exemption and that sort of thing, orderlies can continue to function and perform their ordinary tasks and have other tasks delegated to them from time to time depending on training and skill.

At the end of my written submission I have appended the policy of the College of Physicians and Surgeons of Ontario on delegated medical acts, which delegate certain tasks to nurses and other health care professionals. That, I think, is a very useful model for considering regulations for other health care professionals because it specifies certain categories or acts which should be delegated to a registered nurse. While they do not do it in this particular enactment, the College of Physicians and Surgeons could specify respiratory therapists or medical lab technologists or any other regulated health profession to have governance or delegation of certain actions, controlled acts.

On the other hand, they also take certain acts and delegate them to a designated person who is trained in the procedure and certified in the procedure. Once that training and certification exists, that person is then competent to perform those procedures. I think that is a balanced approach for registered nurses and it is also a balanced approach for orderlies, as and if the nursing profession or the medical profession want to expand their scope of practice.

Basically that is what I want to bring to the attention of the committee because, as I say, the particular prohibitions would prohibit urinary catheterization and the giving of enemas and disimpactions, things of this nature, on patients because they are beyond the urinary meatus or beyond the anal verge. Certainly, on behalf of myself and other orderlies, I would like an exemption from that or delegation, or both, to deal with that situation.

As I say, orderlies have been performing these tasks within Ontario for at least 50 years and probably quite a few years before that. They have grown with the profession and are integrated into the health care system, particularly in public hospitals but also in some of the other institutions, the nursing homes and things of this nature. They also are often involved in psychiatric patient care as psychiatric attendants, with many of the same duties. Urinary catheterization also comes up in those institutions; so do enemas. Those are tasks that are ordinarily performed by orderlies, among other health care professionals.

In the United States, just recently the American Medical Association has instituted a program to parallel both the registered nurse and licensed practical nurse programs to bring more people into the health care system. It is called the registered care technologists proposal, and they have set up pilot programs to train people in three levels of delivering care to patients. Their idea is to supplement the auxiliary nature of people who are able to help nurses and LPNs in their practice, and to deal to some degree with the problems that come up with the shortage of nurses and things of this nature in the US.

That proposal is still in the pilot program stage, but it is some indication of the way in which the US is perhaps going to be dealing with these issues. They will be proposing licensure. I would suggest, in the longer term, that licensure might be a route for us to go as well with the College of Nurses, either licensure of the group itself or licensure of the particular delegated acts and procedures.


The Chair: Thank you for your presentation. If there is anything additional that you think would be helpful for the committee, we have all received your presentation, and you certainly can continue to communicate with us in writing. The parliamentary assistant has asked to clarify some of the questions.

Mr Wessenger: I would like to add that we do not see this legislation as having an impact on orderlies, for the simple reason that section 27 of the act still permits delegation by a health profession and we can see that continuing. We still see standing orders continuing which would allow you to do certain acts.

The other things with respect to outside of the institutional setting, there is an intention to exempt attendant care by regulation with respect to the matter of care given in nursing homes, for instance, and so forth. This type of activity would be permitted in the nursing home setting under the regulations.

Mr Hebert: Thank you very much, sir. I realize that exemption was there. I believe Mrs Caplan first mentioned it and then it was confirmed by Mrs Gigantes in a statement to the Legislature when the bills were introduced. My concern is that you be aware of this problem and that the delegation by regulation address itself to the idea of orderlies and others performing these tasks.

The Chair: Thank you very much for appearing before the committee today. For your information and everyone else's, Hansard is here. Your presentation is on the record and your written presentation is also part of the public record.


The Chair: Barbara Conlon, come forward. Welcome to the committee.

Ms Conlon: Good morning, Madam Chairperson and members of the standing committee, and welcome to London. I am pleased to be able to present my concerns with Bill 57, the Nursing Act, as part of Bill 43, the Regulated Health Professions Act. I appreciate the commitment you have made to hearing my feelings on how this proposed bill will certainly affect the present level of health care I am able to offer.

My name is Barbara Conlon. I am a registered nurse working in a large health centre for southwestern Ontario currently designated as an obstetrical tertiary care centre. The past 16 years I have spent in the field of perinatology, the care of mother and foetus, aimed at an outcome of a healthy mother and child. By relating some personal experiences I will demonstrate how this bill will affect the delivery of safe and optimal care in my field of practice.

Working in a hospital places me in the unique position of being an employee subject to the directions of my employer, as well as being regulated by an outside governing body. As an employee, I am obligated to my employer even if I feel it may compromise patient care. For example, I am told, "Next Sunday you're one nurse short and she won't be replaced." The delivery room is very unpredictable and situations demanding nursing care are always changing. I realize this can lead to a potentially dangerous situation for my patients. I know I will not be able to give the optimal care deserved by my patients. The employer has failed to recognize my needs to work under conditions conducive to giving optimal care.

As an employee, I am under the control of nursing managers and supervisors. A supervisor will decide numerous things in a day, all of which will affect the care given to the patient, for example: "The sick call won't be replaced. You'll have to work short. I know you're busy, but you'll have to do the best you can. I know you can do it," or: "Barb, you have to go to ICU. They're busy. Yes, I realize you haven't worked in ICU, but a nurse is a nurse and they need a body. You have to go. If you refuse, I'll speak to your manager."

Ladies and gentlemen, the above examples happen every day. I am being asked to be part of a dangerous and unsafe situation which could leave the patient in a compromising situation. Because I am a hands-on care giver, because I am the person with the most patient contact, I will be the person who has to answer for her actions if any questions should arise. The supervisor/manager who decided not to replace staff, to send me to ICU, may answer to another manager but not to her governing body as she or he is not designated as the hands-on care giver. Obviously patients are ultimately affected by their decisions and, for this reason, I feel administrators, supervisors and teachers must be held accountable.

By not including these nurses in our scope of practice, by not recognizing the role of the employer in the delivery of safe and optimal care, this bill has failed to address a serious ongoing situation. I fear that examples such as I have cited are only going to continue to escalate. Protection of the public through safe patient care is lost. The budget, as important as it is to all taxpayers, is often the only concern, unfortunately at the expense of patient safety.

With the introduction of this bill you are opening the door to fragmentation of the health care system. Without licensing of my scope of practice you have allowed other less qualified health care personnel to perform my functions, most likely at a lesser cost. Licensing denotes control over. Without this, employers will feel free to substitute a somewhat less consistent caring approach for a more skilled and experienced nursing care, as well as a higher level of safety.

For example, respiratory technologists are now suctioning neonates' endotracheal tubes and attending deliveries of the potentially ill foetuses. In an outpatient department for high-risk pregnancies secretaries with no medical background are weighing patients and checking urine for protein and glucose.

Both these sets of workers feel this is great; it gives them more justification for their position. But tell me, is that respiratory technologist giving the same compassionate care as the nurse who is at that bedside of that sick infant 24 hours a day? Can they assess the baby's reaction when they have another 10 infants to suction? Will they be readily available if emergency suctioning is needed? Having worked in the neonatal intensive care unit for eight years, my answer would be no.

In the case of the secretary, would she be able to recognize the significance of too much or too little weight gain? Would she be able to counsel the patient as to Canada's Food Guide and pregnancy? Would she be able to recognize the symptoms of pregnancy-induced hypertension? Having worked in the high-risk obstetrical department for eight years, my answer is no.

Licensing of my scope of practice would protect the patient's right to safe and adequate care and help to maintain my level of job satisfaction.

I would like to relate to you a happening as it relates to the delivery room nurse in Bill 57. Specifically, I would like to address the limitation on controlled acts, as set out in the bill, as it relates to the care of a labouring patient.

A woman walks through the door, obviously in great discomfort. I greet her, put her in a room. I check the foetal heart, assess, by hands-on manipulation, foetal position and the state of contractions. She tells me she feels like pushing. She would like an epidural. She asks me if she is in labour. She wonders if her baby is okay. She ruptures her membranes and the fluid is a dark green colour, normally clear.

What am I to do? If Bill 57 is passed, I cannot do any of the above as that would constitute management of labour. You have restricted me from examining her cervix until I get an order. Too bad the physician and/or qualified person is stuck on the elevator. I cannot answer her questions because that would be considered communicating to the individual a conclusion identifying a disease, disorder or dysfunction as the cause of symptoms of the individual, etc. I cannot apply a foetal heart monitor for assessment as that constitutes a form of energy. As an experienced nurse I know the patient needs all of the above, along with verbal reassurances. Somebody please check the elevator.

The baby has delivered. She has difficulty breathing. She needs suctioning. Where is that qualified person when I need him or her? Too bad I cannot use my years of experience with neonates to give fast, effective needed care.

If I had gone ahead and applied the foetal monitor, if I had checked for dilation, if I had told the patient she was in labour and the amniotic fluid was off-colour, or if I had suctioned that baby, I would have been doing what I feel is giving safe and compassionate care to a labouring patient.

If Bill 57 is passed, I will be scrutinized not only by my employer and the college, but by any other regulated health profession that may feel I have overstepped my bounds. Based on this one small example, I find it difficult to see how you feel this bill is for the protection of the public and ensures the system operates with maximum efficiency.

In conclusion, I would like to say: Any decision made affects the quality of care. Therefore, all nurses must be made accountable for their decisions. By failing to license my scope of practice, you are subjecting my patients to increased fragmented care. The proposed legislation has failed to grant me the right to perform controlled acts independently.


Therefore, you have defeated the objective of this legislation: the provision of high-quality care, operation of a system with maximum efficiency and protection of the public from unqualified, incompetent and unfit health care providers.

To invade our practice, to put limitations on what we are already doing, what we feel is part of competent and compassionate care, is unthinkable. I would like you to think of nurses as productive assets of the health care system. Let us continue in that role to ensure the public do receive safe and competent care.

At this point I would ask you to consider my written submission regarding the Midwifery Act. I do believe in the right to choose an alternative method of childbirth, but just as firmly, I do believe that midwifery should be a speciality of nursing just as obstetrics is a speciality of medicine.

I welcome any questions you may have and I thank you very much for this opportunity.

Mr Beer: Thank you very much for your presentation and in particular for the examples that you set before us because, as is often said, we are laypeople and that can be helpful in seeing how you actually work. I wonder if I could ask the parliamentary assistant, in terms of the description of a number of the functions here that were set out where the witness has said that in her reading of the legislation she would not be able to do a number of those things, is that in fact the case in the way the drafters of the legislation intended that? How would those situations be handled?

Mr Wessenger: In general, I will answer the question by saying that I think the legislation permits those acts, but I will ask the ministry staff just to do it in detail.

Mr Burrows: A number of the situations that were described were emergency situations. If you look at Bill 43, section 28, you will find that it reads, "An act by a person is not a contravention of subsection 26(1)" -- which is the list of controlled acts -- "if it is done in the course of, (a) rendering first aid or temporary assistance in an emergency." So, for anyone, be he regulated or unregulated, there is a blanket provision for emergency situations.

Second, in the institutional setting we do have standing orders and protocols which can apply in which there is an agreement that in a certain situation, the professional team will behave in a certain way.

Third, there is specific delegation permitted and we have heard with previous presenters that issue discussed. I would also like to point out that nursing presently does not have a licensed scope of practice. Nurses under the Health Disciplines Act are treated differently than the other professions under the Health Disciplines Act. The other professions are licensed; nurses are registered. In the new scheme no profession will have a licensed scope of practice. Rather the only thing that will be controlled will be the specific potentially hazardous acts. I would like to clarify that nurses will have the same regulatory system as all other health professions.

Mr Beer: If it is made clear in terms of the work of the committee in the final passage of the legislation that you can do those things and are able to do those things, would that then meet the concerns that you have raised here? We have heard a lot about standing orders and protocols. Are those workable, effective, in terms of the kinds of things you can do?

Ms Conlon: In the case of standing orders, no. They are not an effective way to deal with this. We have used standing orders in our institutions and a lot of institutions are eliminating the use of standing orders.

Number one, it is very easy to just pick out number three, four, five and six of standing orders 1 through 20 and apply it to this patient before walking into that room and doing an individual assessment of that patient and figuring out exactly what his or her needs are. So you are eliminating the individualized care by encouraging the use of standing orders.

Number two, working in a teaching facility, we have found that we work with clinical clerks, interns, every level, physicians who do not understand the significance of some of those standing orders that have been written. Therefore, we found that we could not use them. Even in an emergency you still have to have the authorization to use that standing order. You still have to phone someone to get the okay to use the standing order you have, and that is without anyone seeing that patient. I think what we would lose is the individualized assessment of the patient by getting back to the using of standing orders.

Mr Owens: Further to Mr Beer's question around standing orders, other members of your profession as well as your association have raised the concern around physicians refusing to retroactively sign for the order. Have you personally or do you know of any of your colleagues who have in fact been placed in that position where a physician has refused to retroactively sign?

Ms Conlon: Yes, I have on frequent occasions. You will be walking down the hall; they will say: "Yes, that's okay. Do that." You will write the order down or you will take the chart to them personally and you will stand in front of them and you will say, "Please write that order." "I can't remember when I wrote that order. There's no way I can sign this." It happens to me. In 19 years it has happened to me on a very frequent basis.

When I worked in a outpatient department, I was constantly on the phone getting orders for the things I was doing. By the end of my time in there, all they were saying was, "Oh, no, it's Barb again." But they were giving me the orders I wanted. But yes, we do run into circumstances where they will, because they might not be able to see you for an hour or two after that order or to get the order signed and then they will say, "Barb, I don't remember telling you to do this." We have run into serious circumstances with that.

The Chair: Thank you very much for your presentation before the committee. We would encourage you, if there is any additional information you think would be helpful, to submit it in writing through the clerk. We thank you for appearing today.

Ms Conlon: Thank you very much. Have a good afternoon.

The Chair: I have some housekeeping issues for members of the committee. First of all, we would ask that you check out of the hotel over the noonhour. Bring your bags here. There has been a change in flight time for those who are flying out after the hearings. We will be leaving the hotel at 4:45 for a 5:25 flight which will arrive in Toronto at approximately 6:05. Please make a note of that and inform anyone who needs to be informed of that change, but we will be leaving the hotel today after the hearings at 4:45.

The most important item is that normally the committee meets in the afternoon at 2 pm. However, today we have a delegation appearing at 1:30. I would ask you to note that so we can begin the hearings as scheduled promptly at 1:30. The meeting now stands recessed until 1:30 pm.

The committee recessed at 1158.


The committee resumed at 1330.


The Chair: I call Ian Galbraith. You have 10 minutes for your presentation. All members have received your written submission. We would ask if you would leave a few minutes for questions at the end.

Mr Galbraith: Thank you for the opportunity of speaking before the committee this afternoon. My name is Ian Galbraith. I am a registered nurse currently employed on the regional rehabilitation unit at Parkwood Hospital here in London. I am an active member of the Ontario Nurses' Association and am known to several of the committee members.

I am submitting this brief from my own perspective, but it may appear in many areas that it is in harmony with what you have already heard from the Ontario Nurses' Association, other ONA members and other staff nurses. I also note that it is in harmony with some of the recommendations of the College of Nurses of Ontario and the Registered Nurses' Association of Ontario brief that has already been submitted to you. This is not coincidental. The ONA presentation has only echoed the concerns that we hold as day-to-day practitioners of nursing. I urge you to review in depth their lengthy document.

Nurses in all cases are working to improve the overall health of patients. Nurses are the only professional group who are not interested only in some small aspect of patient care but are interested in the whole person and the continued improvement of health and health promotion.

I would like to recommend a book to all committee members by Sarah Jane Growe called Who Cares? It is an excellent book and highlights the ongoing issues that are occurring in nursing and in the health care field.

Though I am generally in favour of the government's plan with this proposed legislation to allow the general public the widest possible choice in choosing who should look after their health care, I quite simply have many questions and fears that I see with these acts as they are proposed.

It should be noted that nurses are in a unique position today since they now are under the Health Disciplines Act. We are in a triple jeopardy situation, being answerable to our clients, to our professional body and to our employer. If an employer or a manager orders a nurse to do something that is unprofessional or unsafe, the nurse is caught in a bind. To not do so risks charges of insubordination or dismissal; to do so runs the risk of sanction by the college of nurses.

Labour law has no mechanism for professionally sanctioning unprofessional or unreasonable actions by nurse administrators, educators or researchers. Should a nurse administrator knowingly employ an unsafe nurse who is repeatedly doing unsafe acts, the administrator can receive no direct sanction from the college of nurses. In the recent past here in London a nursing director had been repeatedly warned that a nurse was unsafe and unprofessional, and yet she did nothing. It was only after a gross violation that the higher management stepped in, fired the nurse and then contacted the college of nurses. The nursing director, who had been aware of the situation for months, was untouchable by the college because she had done no direct patient care.

In my brief I also cite another example to show why we, as nurses, are asking for the inclusion of nurse administrators, educators and researchers under the nursing act so that they can be fully accountable to the college for their actions and their practice.

With regard to the licensed acts under Bill 43, I believe the legislation is taking the wrong tack with regard to licensing and the scope of practice of professionals. Instead of licensing the profession of nursing with a defined scope of practice, this legislation will allow anyone, no matter what his qualifications, to provide nursing care or treat a health condition for remuneration as long as he does not call himself a registered nurse or a registered nursing assistant, and does not perform a licensed act as defined in the RHPA, Bill 43 and Bill 57. This differs definitively from what is law in British Columbia and Nova Scotia, where the nursing scope of practice and the name "nurse" is protected.

The RHPA is not going to protect the public from unqualified or semi-qualified persons performing nursing care where it is not covered by the RHPA but is now in our scope of practice.

In my brief, I have highlighted several areas of my concern with the licensed acts. If I can highlight just one example, I would like to refer to page 5, the example of a patient who is newly admitted with a new tracheotomy. Should I have to wait for a doctor's order to suction that tracheotomy with a catheter? Even if an order has been written? Even if the chart reads, "Trach care QID+PRN," meaning four times per day or as necessary, and "Suction QID," meaning four times per day? This is taken verbatim from a chart.

What happens on the fifth time that patient needs suctioning? Do I wait, call the doctor, wait for a return call and watch the patient choke or start to drown in his own secretions? Or do I perform suctioning without an order and risk the sanction by the college of nurses for performing a licensed act beyond what the order now reads? Right now, I perform the suctioning because it is within my scope of practice, but after the RHPA, it is not. Who will decide what a qualified person is and who also will decide what constitutes an emergency?

As a committee, you may feel I am an alarmist in questioning these many potential traps and dangers found in the proposed acts. I do not feel I am being an alarmist but pointing out where the legislation is flawed and open to too much interpretation or question.

It has been suggested that local hospitals and agencies have standing orders or should have standing orders to cover nurses over the cracks in today's legislation, or those with the RHPA. I have cited from my own hospital manual, which states that there are no such things as standing orders in the hospital except in three very specific areas.

Finally, why do nurses have such apprehension surrounding the proposed acts and the areas that we practise in presently, which will be out of our sphere of practice with the RHPA? Some of that flows from the heavy-handedness of the present college of nurses and its current practices. It only takes a small complaint for a nurse to find herself or himself before the discipline committee of the college fighting for his or her certificate of confidence.

This may sound ridiculous, but if you refer to appendix A in my presentation, you will see that last December a nurse was called before the disciplines committee, having already passed through the complaints committee of the college, because he had overdue hospital library books. If overdue library books can take one before the discipline committee of the college, then I question whether performing an act once too often, or bordering on the edge of an unauthorized licensed act, surely would. To face a $25,000 fine or six months in jail for suctioning a patient five times in one day is truly scary for any nurse.

I have made a number of recommendations in my brief. In summary, I support the thrust of the bill to open the health-care system to the widest amount of choice for the consumer. My recommendations are based upon what I have experienced and what I have heard from other working nurses today. With the recommendations I have made, and those of the Ontario Nurses' Association to you, the standing committee on social development and the present government can make a good health system even better to work in and to be a consumer in.

Mr Hope: I would like to focus on your recommendation A, if you do not mind looking at that. I hold particular interest with the triple jeopardy that you have been bringing forward and we have been hearing throughout. You are saying to bring them under the college of nurses. What if they were under a separate administration or a separate accountability part of legislation? Would you want them part of the college or should they be a part of a separate one that holds accountability -- making sure enough staff is there, making sure that when there are budget cuts that they are not jeopardizing a patient's health? Should they be accountable to a different body other than the college of nurses? Because you have not only the nursing administrators, but you still have another tier above that.

Mr Galbraith: Yes, that tier above. In my brief I do discuss to some degree the point of going beyond and having other people brought under the nurses' college. It is very clear that nurse administrators, educators and researchers could be put under the college. I also recommend that other people who are administering other professionals be accountable to someone. I am not sure exactly who that should be, whether you should create a third college, whether you should create some kind of other body. I think also if someone is in charge of, say, a physical therapy department but is not a physical therapist, or is in charge of a nursing department and is not necessarily a nurse, yet a nurse has to be answerable to them, then that person should be accountable also.

Mr Hope: That is really our particular interest. You are trying to get the weight off your shoulder by making other people accountable, but then there are other people here who have to answer to somebody else. We had to make the whole system accountable. That is why I posed that question.

Mr Galbraith: Accountability is important, but as it stands now, the only one who is accountable to the college is the person who is actually doing the hands-on care.

The Chair: Thank you very much for your presentation. We appreciate hearing from you today. I know that you are aware that if there is anything further you wish to communicate to the committee that you can do so in writing at any time.



The Chair: I call the Interfaith Pastoral Counselling Centre and the Presbytery of Waterloo-Wellington. You have 20 minutes for your presentation. I would ask that you begin by introducing yourself to the committee for the purposes of Hansard, and leave a few minutes at the end, if you would, for questions from committee members.

Mr Henderson: My name is John Henderson. I am the executive director of the Interfaith Pastoral Counselling Centre in Kitchener. I am also a member of the Presbytery of Waterloo-Wellington and the Presbyterian Church in Canada. So I am here wearing two hats today and hopefully I can weave them through.

I am not familiar enough with the legislation to offer a lot of constructive suggestions. Rather, I would like to simply indicate some concerns that I have, coming from where I do, as a clergyman and also as an executive director of our centre.

Interfaith was established in 1968 as a centennial project of Trinity United Church in Kitchener. The purpose was to provide qualified counselling to people, regardless of the ability to pay. While rooted in the Judaeo-Christian ethic, the commitment was to offer counselling that respected and honoured the value and belief system of a multicultural and multifaith community. Hence the name Interfaith. Second, its purpose was to train counsellors. Initially, much of the training was taken by clergy, but quickly expanded to include others in the community and surrounding area. Over the years, with informed and visionary leadership, Interfaith has grown in both its counselling and training programs.

In its earliest days, Interfaith's training program cultivated connections to Wilfrid Laurier University through the Waterloo Lutheran Seminary. Today, Interfaith offers 11 academic courses at the master's level at Wilfrid Laurier University. In 1987, Interfaith was the first training centre in Canada to be accredited as a teaching centre by the American Association of Marriage and Family Therapy. The University of Guelph is currently the only other such accredited centre in Canada. Interfaith relates to AAMFT through the Ontario Association for Marriage and Family Therapy. As well, Interfaith has been accredited as a training centre for 11 years by the Canadian Association for Pastoral Education.

Currently we have six professional staff, all of whom are clinical members and approved supervisors of AAMFT. The training program is two years in duration and has 26 interns. To qualify, interns must be able to work clinically and academically at the Masters Level. We have a pre-intern program that has 127 students enrolled. Interns strive to become clinical members of the AAMFT. This membership represents, at a minimum, a master's degree in a behavioural area, 11 academic courses in marriage and family at a master's level, and a minimum of 1,000 hours of marriage and family therapy conducted under approved AAMFT supervision.

The other hat I am wearing today is that of clergyman. For 20 years, from 1968 to 1988, I was pastor of four congregations. For the past 19 years, I have been a member of the Presbytery of Waterloo-Wellington, whose boundaries correspond to those of the Waterloo-Wellington counties.

One of my major interests has been the recruitment, processing and screening of candidates for the ministry. As you may guess, my long-time interest has been in the pastoral relationship of pastor and parishioner. It was early in 1973 that I personally sought out training at Interfaith counselling, and completed that training in 1980.

Recently, my presbytery requested that I make representation to you regarding Bill 43, the Regulated Health Professions Act. My ministerial colleagues are dismayed by their understanding of the proposed legislation.

From a legal opinion, I understand the following; I assume from another presentation you have already had this documented by Morris, Rose, Ledgett, barristers and solicitors in Toronto.

1. The Regulated Health Professions Act seeks to replace the prohibition of the practice of medicine without a licence contained in the Health Disciplines Act by a series of controlled acts, which only a medical practitioner -- or, in the case of a few of these acts, some other regulated professions -- is authorized to perform.

2. The act provides for the establishment of a college for each of the regulated health professions. It defines the scope of practice of each of the professions by setting out a list of controlled acts which a member of that profession is licensed to perform.

3. The legal opinion states that a difficulty has arisen with respect to the medical profession in particular. The act has attempted to define the practice of medicine by reference to a series of controlled acts, including in paragraph 26(1)1: "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 it is reasonably foreseeable that the individual or his or her personal representative will rely on the conclusion."

This diagnosis clause is intended to prohibit anyone who is not a medical practitioner, except for members of other regulated professions such as dentistry, psychology and chiropractic, who can diagnose within a restricted area, from communicating a diagnosis to an individual.

4. By attempting to broadly regulate the diagnosis of diseases, disorders and dysfunctions, the clause potentially proscribes the legitimate exercise of the practice of a large number of unregulated health care practitioners. The legislation potentially includes within its scope a number of activities previously legitimately performed by unregulated practitioners. There is no indication in the act that the intention of the legislation is to prohibit unregulated practitioners from communicating assessments in accordance with the distinctive training and explanatory framework of the disciplines in which they have studied and trained, yet the vagueness of the terms "disorder" or "dysfunction" as "the cause of the symptoms" could very well likely lead to such an outcome.

5. The limitation that the diagnosis must be "in the course of providing health care services" does not provide effective protection to an unregulated practitioner. Health includes mental health, and therefore the counselling that marriage and family therapists and ministers provide could conceivably come within the bounds of this restriction.

My concern also is with sections 36(1), 37(1) and 38(1) and (2) of the act, which outline the liability of employment agencies, responsibility of employers and the responsibility of directors of corporate employers. They outline the liability of $25,000 and, in the first instance, imprisonment for a term of not more than six months.

The Regulated Health Professions Act makes marriage and family therapists, the staff and board of directors of my centre, Interfaith Pastoral Counselling Centre, and all clergy potentially liable under this proposed act. At least, this is how my people are responding to it. I and many of my colleagues find this distressing and dismaying.

Recently, I was part of a coalition in Kitchener-Waterloo of eight counselling agencies that provide counselling to clients on welfare. Among our counselling, we do clients on welfare and income assistance. We met with four area government politicians who praised us for providing counselling services to the needy, the disadvantaged and those who have no advocate. We were lobbying in this instance for more government funding, as government funds fall short and we have to fund-raise to provide this service. In the next breath, when questioned about the proposed act, they responded that it was going to go through as is. May I be forgiven for finding this attitude cynical. In 1989, these agencies provided 31,899 hours of counselling to those on social assistance. This is a statistic taken from a study by the Waterloo Region Social Resources Council, June, 1991.

My submission today is more of a protest and a request to make the proposed act less vague. If, as the legal opinion states in 1, 2 and 3, which we have gone through, that the intention of the act was to address the medical profession, then could that not be made crystal clear and limited to that? Otherwise the proposed act appears to discriminate against the legitimate exercise of the professions of marriage and family therapy and its training programs, and our province's clergy. From where I and my colleagues sit, we feel the proposed act isolates us, points a finger at us, identifying us unnecessarily as liable to prosecution. To allow the courts to make decisions on our liability in this manner is financially unwelcome by us and would sow seeds of resentment towards our elected representatives. I contend that nothing is gained by that. That is all I have to say.


Mr Beer: Thank you for your presentation. I think, as you are aware, this issue has come up fairly frequently, and it is also fair to say that there are different interpretations as to whether in fact the clauses that you mentioned do what you think they might, but I think as a committee we are seized of the fact that there are people who think it might do that and so we are concerned about that one.

The Coalition of Unregulated Practitioners did put forward a number of possible changes and I was wondering whether you and your organization had seen those or were part of that and whether you had any particular preferences that included exempting clergy or rewording the clause.

Mr Henderson: I just received this, actually, two days ago, so I have not had time to digest it. I have not been actively part of the coalition in terms of attending meetings.

Mr Beer: That is fine. I think there are some proposals there, and I would simply say if there was something there that you thought met the arguments and the concerns that you had, you could perhaps let us know in writing and that could go with your brief.

Mr Henderson: Sure.

Ms Haeck: Thank you, Mr Henderson, for your submission today. In a way, I am following up on what Mr Beer has already questioned you about. While the Coalition of Unregulated Practitioners has put forward a clause -- and I have also heard from other clergy in my own riding who share a similar concern -- I do want to pose a question to you with regard to clause 28(c), which has been viewed very favourably by the Christian Science denomination, which came before us yesterday, which states, "treating a person by prayers or spiritual means in accordance with the tenets of the religion of the person giving treatment." In fact, this was an exemption for those people who use spiritual means. Do you feel that is adequate protection to continue counselling within the church environment?

Mr Henderson: Off the top of my head, I do not think so. I think your reading was, if I remember correctly, those who use prayer.

Ms Haeck: Yes, "An act by a person is not a contravention of subsection 26(1) if it is done in the course of," and (c) does mention treating the person by prayer or spiritual means.

Mr Henderson: That is too narrow, in my mind, as an exemption.

Ms Haeck: I see. Thank you very much for your opinion.

Mrs Cunningham: I guess my concern is with your main reason for being here. Your input is similar to the input of your colleagues across the province, Reverend Henderson, and I would just like to say that certainly we are sitting here to make changes, where changes are appropriate, and to make recommendations as a result of the hearings of this committee. I would hope that would be your intention as you go back to your community to let your community know that there will be changes as a result of these public hearings. I am sorry that you were told otherwise, and I certainly hope that my colleague Elizabeth Witmer was not one of the people you met with.

Mr Henderson: No. By government I meant elected to government, the people in our area we met with.

Mrs Cunningham: Perhaps the government representatives could discuss that with their own colleagues. There is nothing worse in these public hearings than to come here thinking that people are not listening. All of us here are here to listen and make changes as we feel appropriate. I am certain that the Chairman will be making recommendations on behalf of the committee here as a result of these hearings.

Mr Martin: I appreciate your coming before us today. Historically, churches have spoken up on behalf of the people they serve, although so far in the numbers of deputations that we have heard from church groups I have not detected any real effort to hear from the people you serve. The intent of this legislation is to enhance delivery of services, but it is also very much to protect the public, and some of the things that are in here are to make sure that the public in fact is being protected. I am wondering, have you spoken to any of your colleagues about what they are getting back from their parishioners regarding this legislation so that we might somehow be enlightened re their perspective on all of this?

Mr Henderson: Only more from the clergy who -- as can be expected, there are a lot of people who are not quite familiar with the details, about the vagueness, and so there is a lot of hysteria that can come out of that and some concern about the quality of the relationship between the pastor and the parishioner and what the pastor will or will not be able to do.

I think all of us -- at least, the people I work with -- are quite concerned that there be accountability within the professions. In our agency, for example, we have developed a pamphlet which we give to all clients that specifically mentions that if they have some uneasiness around business relationships, sexual relationship, etc, they are to contact our director of counselling, who is a female. We are trying to be sensitive to what is happening in our society right now in upholding a fairly substantial ethical viewpoint. We have our code of ethics, for example, in our waiting room. I think clergy are quite concerned about this as well, perhaps in reaction to what has been happening in the last number of years, but still that is very much there.

In a sense we support, I think, what the intent of this act is attempting to do, but I am wondering if there is not more requirement upon each body to regulate itself, and if it is not going to regulate itself, that is when the civil authority moves in. I think in the marriage and family therapy field we are fairly strict, the Ontario Association for Marriage and Family Therapy anyway. If I have what we call a dual relationship with a client within two years after I have terminated counselling with this person, I lose my credentials. I think that is fairly strong, and that has been there for some time, and I support that. I think that is excellent. So there is regulation going on among us, and I am wondering if we could not build more on that.

Mr Hope: Just to elaborate a little more on some of your report talking about whether it is worth while coming here and making presentations, I will refer you to the opening remarks of the minister when these hearings started that she was open to change, because we needed more of a consultation process as this thing has taken place since 1982. I guess how much of it will be open will be subject to discretion, but a number of the clauses that are coming forward to us the minister understands, especially your specific dealing with the social service aspect of it and the diagnosis clause. Yes, we are definitely looking at that, and I think we have a non-partisan committee here. Most of the time we have partisanship, but I think this committee itself is working on a non-partisan basis to make sure that we can rectify the problems in the health care system. That is just to reassure you.

Mr Henderson: Good. Thank you.

The Chair: Thank you very much for your presentation today. I appreciate your coming before the committee. If over the course of the hearings there is additional information that you think would be helpful to the committee in its deliberations, please feel free to communicate with us in writing. For the information of everyone here, the expectation is that clause-by-clause examination of this package of legislation will begin after the House resumes, which will be after September 23. Thank you very much.



The Chair: Next is the University of Waterloo school of optometry.

Dr Cullen: I am Professor Anthony Cullen, and I am associate dean of science and director of the school of optometry at the University of Waterloo. In addition, I sit on the Ontario Council of University Health Sciences. I have been a consultant to the World Health Organization, the United Nations, the American army and to the National Research Council of Canada. My area of expertise is physical energy phenomena effects on the eye. Accompanying me today is Dr Graham Strong, who is an internationally recognized authority in the rehabilitation of the visually handicapped. He will describe to you, should you wish, the many diseases for which there is no known medical or surgical treatment which we are able to diagnose and treat. Also accompanying me today is Dr John Flanagan, who is also a world-recognized authority. His area is advanced diagnostic techniques of the eye, and his special area of expertise is in the early diagnosis of glaucoma. His research is funded by the Medical Research Council of Canada. Since at an earlier hearing you were supplied with misinformation concerning glaucoma, he will happily be able to supply you with the difference between diagnosis of glaucoma and mere screening, which can be performed by technicians or lay members of the public.

I would like to thank the standing committee on social development for this opportunity to present the concerns of the University of Waterloo school of optometry. Certain aspects of this tandem legislation under consideration would seriously compromise our ability to provide contemporary, high-quality optometric education and clinical services in the province of Ontario.

As many of you may know, the University of Waterloo offers one of only two programs in optometry in Canada. The other is at l'Université de Montréal. The majority of optometrists in English Canada are alumni of the University of Waterloo. If legislation regulating the optometric profession in Ontario is retrograde or lags behind that of other provinces, our ability to educate optometrists within Ontario would be the most constrained and restrictive in North America. To provide interns with the requisite clinical exposure for a competitive optometric education, it would be necessary to arrange supplemental clinical teaching placements outside Ontario in other provinces or even in the United States. This would create an additional cost for optometry students and their families. In addition, there will be little incentive under such restrictions for University of Waterloo optometry graduates to remain in Ontario.

The executive summary to the Regulated Health Professions Act claims that the general scope statement "will guide educators when they design and update curricula." Were we to accept the proposed scope of practice and authorized acts of Bill 60, radical changes would be required to eradicate portions of our current curriculum. We have provided you in table 1 with details of our current curriculum. This would, in addition, have serious repercussions not only in Ontario but across Canada, and would potentially jeopardize our accreditation as a school of optometry.

The optometric education program produces an externally verified level of expertise that extends well beyond the proposed scope of practice for Ontario. Doctors of optometry graduating from the University of Waterloo are the best-qualified primary care -- and I emphasize "primary" -- professionals to assess,diagnose, treat and prevent diseases, disorders and dysfunctions of the eye and the visual system.

The proposed limitations to the existing scope of optometric practice represent a clear contradiction of the Ministry of Health's own assistive devices program policy, which we have provided for you in the brief, and Revenue Canada's policy, which recognizes optometric expertise in the diagnosis of diseases of the eye and visual system.

Through regressive semantic manipulation, the proposed scope of practice would unfairly diminish the current activities of Ontario optometrists. The only remaining community resource outside of the major cities for Ontario residents would be the general medical practitioners. They are ill-equipped to diagnose and manage diseases, disorders and dysfunctions of the eye and the visual system.

The standards by which the controlled acts have been delegated to medicine have been in accordance with the highest common multiple, whereas for optometry it reflects the lowest-common-factor approach. Few physicians are capable of performing each and every one of their controlled acts, while most optometrists are capable of greatly exceeding the limitations of their controlled acts. This approach is unfair to the legitimate majority of optometrists in Ontario.

By stifling the legitimate scope of optometric practice, the proposed legislation fosters underexploitation of the established excellence of our optometric education program and an underutilization of the established clinical prowess of our graduates. This situation is unfortunate for the people of Ontario who rely heavily on the availability of full-scope optometric services within easy reach of their home. The individual people in the province will ultimately pay a premium for less accessibility and inferior health care services.

The issue to be considered is demonstrated competence in the provision of important health care services to Ontario residents. There is no room for polemic mediation of these issues. Optometrists are amply qualified to continue to provide extensive eye and vision care services to Ontarians. They are accessible to all provincial residents. The quality of their services is recognized by the public, by government and by academic and scientific communities. They have consistently demonstrated a responsible and co-operative interaction with government agencies and with other members of the health care team. In the region of Waterloo, there is no conflict between optometry and ophthalmology. We respectfully suggest that the subject of this legislation is health care, not medical care.


The Chair: Thank you very much for your presentation. Question, Mr Wilson?

Mr J. Wilson: Perhaps it is more of a clarification from the parliamentary assistant. Given this evidence and other evidence before us previously, why in the Optometry Act were optometrists not given the diagnostic controlled act? Could we have the ministerial reasoning behind that?

Mr Wessenger: I will refer that to staff, although it should be noted that they are given some diagnostic aspect with respect to dysfunctions of the eye. I will refer to staff the reasoning for the limitation.

Mr Burrows: Not having been a member of the review team, I cannot properly account for every particular piece of work it did. However, suffice it to say that the proposed act, which is based upon their findings, which is the result of considering all the information that was presented to the review over a period of six years, not only by the profession of optometry but by ophthalmologists, opticians and consumer groups as well, taking everything into account, in the wisdom of the review the decision was that the scope-of-practice statement accurately captured what optometrists do. That statement reads, "The practice of optometry is the assessment of the eye and vision system and the diagnosis, treatment and prevention of vision and ocular motor dysfunctions of the eye."

Since the receipt of the report's recommendations, there has been extensive discussion between ministry staff and not only representatives of the association but the College of Optometrists as well. We have also consulted with other interests in the eye care field for their opinions, and we certainly made considerable progress over that time in terms of coming up with possible alterations and options for changing that statement. However, suffice it to say, we could not obtain consensus.

One of the things I believe will happen before the hearings are complete is that this committee will hear information from some of these other interests with respect to who does what in the eye care field. I really have nothing to add. The statement did capture, in the opinion of the review, what optometrists do. We have heard evidence to the contrary here and in other presentations, but I believe you will hear additional comment from other parties in the field of eye care before the hearings are finished.

Mr Beer: I do not want to put words into your mouth; I want to just make sure I am clear. In the concerns you have as to how in your view your scope of practice is being limited, I take it that it is through the ophthalmologists who are saying their practice is different and yours should be limited, and that is the crux of the issue. I want to make sure and ask you, is that correct? Then with that, you mentioned the issue of glaucoma and it struck me that was probably an example where you could inform us as to how you would deal with that and why in your terms you were quite competent and capable. So there are two parts to that; I am first just wanting to be certain where the conflict is and then, second, is the glaucoma example a good one to describe to us something you do now that you could not do under this act?

Dr Cullen: Initially I would like to point out that ophthalmology is not a regulated discipline under the act. It is under the umbrella of medicine. We certainly have problems that any physician who may have had very limited education in the eye is permitted to do any act. A solution to this may be to subdivide medicine into specialties.

The ophthalmologist is a specialist. In the United Kingdom, where I originated, they remain specialists. Unfortunately, in Ontario many ophthalmologists practice primary care. Very few do in the region of Waterloo, which is why we get on very well. The problem is using highly expensively and highly trained ophthalmologists to provide primary care. It is illogical.

With regard to glaucoma, I would defer to Dr Flanagan.

Dr Flanagan: Glaucoma does provide a good example. One of the dangers of getting into a conversation specifically about glaucoma -- I would like to point out other aspects of the report and the information provided that go through a whole series of different diseases. If you go to page 14 of the report we provided, glaucoma is specifically listed there. The way we tried to do it is approach it somewhat academically and give you quotations from refereed medical journals that we all publish in, along with the medical profession, to point out from surveys and what have you about who does the diagnosis of these different diseases.

The emphasis is on primary care, in that glaucoma is largely asymptomatic in its early stages, which is why optometry plays such a big part in diagnosing glaucoma. I think it is still this problem of diagnosis, in that with the act as it appears to be presented to us we are not deemed capable of making the diagnosis; that means we are able to assess or to screen for, which means that you make a referral in ignorance. Glaucoma is one way your referral in ignorance would go to the same person that you would refer to even if you diagnosed the condition, which we all believe we do. But there are many other conditions where we, having made an accurate diagnosis, save the OHIP system a great deal of money by referring to the appropriate specialty. One of the points that we really must make is that not all of our referrals go to ophthalmology. We refer to a great many other specialties, and if we are not allowed to diagnose that ability is taken away.

The other aspect is counselling, and this would come under glaucoma too, that the restricted act is one of counselling once a diagnosis is made. That is the thing that we take great pride in, that we certainly spend a lot of time doing. In fact, I would suggest that ophthalmology very often uses our services to provide that counselling, and that will be taken away. Most ophthalmologists, like the ones we deal with in our area, who, as has been said, we get on perfectly well with, do not necessarily feel it is the best use of their time to provide the counselling services, knowing that we can provide those services. Under the new act, we would not be able to do that, so that is another side issue of the whole diagnosis issue.

But it is very clear that the general practitioner, who would be the primary eye care clinician if this act goes through, in the majority of Ontario does not have the necessary equipment or skills to diagnose glaucoma in the early stages. This is not an antimedicine statement. We consider ourselves part of the medical model, as does medicine consider us part of the medical model. So we do not see the conflict. We do not see ourselves as an alternative to; we are just providing something that is not otherwise provided. Really, the discussion here is merely for recognition of what we in fact do. We are not even asking for what we consider our scope of practice to be broadened, which an awful lot of people would want to do in this sort of environment. We now feel we are fighting simply to be recognized for what we have done for years, and which we do very well.

The Chair: I have a request from the parliamentary assistant to clarify.

Mr Wessenger: I would just like to indicate to you that in the act there is no restriction on your doing a diagnosis. The only restriction is with respect to the communication of that diagnosis to the patient. There is also no restriction on your communicating that diagnosis to an appropriate specialist. So there is no restriction on what you say you normally do. Of course, if you even go further, there is no restriction on communicating the results of an assessment to the patient.

Dr Strong: My name is Graham Strong. There seems to be a lot of misunderstanding about what in fact a diagnosis is. The committee seems to believe that a diagnosis is -- that out of an array of naming of disease, there is one that applies to the particular presentation. There is that sense of what a diagnosis is, when in fact a diagnosis is technically a hierarchical process, as reflected in standard systems of diagnosis or computerization of diagnosis. There is an evolving level of specificity. I think it is in that spirit that medicine is given this power to diagnose. A general practitioner can in fact diagnose sophisticated neurological disorders to a certain level of specificity. When that is referred, there is further qualification and clarification which leads to a more precise, if you want, diagnosis.

The initial act is one of diagnosis. The initial act that an optometrist provides, the initial service, is one of diagnosis, and it seems to me that to invoke the expertise of ophthalmology is really to be sidetracked into the level of specificity of that diagnosis in some instances.

Mr Johnson: I wanted to ask a question about glaucoma, seeing as we have a pre-eminent expert in optometry here, but Mr Beer's second question was my first question. I would like to pass to Mr Owens, if the Chair is agreeable to that.

The Chair: No, Ms Haeck is next.

Ms Haeck: I will defer to Mr Owens.

Mr Owens: The hand-off. Thank you, Madam Chair and colleagues.

We had a presentation from a group of optometrists and they indicated, I believe, that there are currently 27 states that allow the prescription of drugs by optometrists. If we were to agree to that request for amendment, as I understand it is being made, would that require a change in your curriculum, or are you already at the level where the prescription of drugs would be just an adjunct to what you are already doing?

Dr Cullen: There has been a change in the number, as Texas now approves the prescription of therapeutic drugs.

Mr Owens: So we are up to 28 now?

Dr Cullen: We are at 28 now. In that many of our students do their post-doctoral residency training in the United States, it is important that they be educated to function in that milieu. Therefore, our students are instructed in therapeutics, as you will see from our curriculum which we have provided. It is not our intention at this point in time to push for therapeutic drugs from the school, certainly. On the other hand, we have to be prepared should these things happen in the future with the natural evolution of the profession. For the question as to whether the change in the current proposed legislation would affect what we do, the answer is no.

The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee today, and I know you realize that if there is any additional information you think would be helpful for the committee, that you will communicate that in writing through our clerk. Thank you very much.



The Chair: I call the London and Area Association of Optometrists.

Dr Van Ymeren: Thank you. I am Dr Harry Van Ymeren, and I am president of the London and Area Association of Optometrists.

Dr White: I am Dr David White. I am the secretary of the London association.

Dr Van Ymeren: Ms Chairperson, committee members, ladies and gentlemen, thank you for this opportunity to present here before you.

We represent the London and Area Association of Optometrists. We are a local study group of 40 practising optometrists. We as a group provide an overwhelming majority of the vision care to the residents of this part of Ontario. We have not been involved in the development of this legislation. We have no authority to either represent, educate, or govern our profession. Our only claim to authority is that we know what optometrists do for their patients. The reason we are here is that Bill 60 does not describe what we do in our offices on a daily basis. We wish to express our concern that the proposed legislation will materially interfere with our patient care.

To highlight our comments, I will describe briefly the standard optometric eye examination. Odds are high that most of you see an optometrist, but I hope to give you the doctor's perspective of what is happening. Then I shall illustrate how the proposed legislation will disrupt how we provide care for our patients.

What we do is in these guidelines, of which you all have a copy, the Guide to the Clinical Practice of Optometry. Guidelines such as these have been published by the College of Optometrists of Ontario for nearly 20 years. The college has the statutory job of protecting the public by regulating the profession of optometry. Revisions such as this recent one are the result of input from both experts and from those of us in the field.

Pages 11 and 12 describe the most frequently rendered optometric service, the oculo-visual assessment. The majority of my day is spent providing this service to my patients. As you will see from the introductory paragraph, the OVA, as we call it, has five components: a history; an ocular health assessment; a refractive assessment; an oculo-motor and sensory assessment; and finally an analysis, which is going on continuously throughout the case history and clinical procedures.

In the interests of time, I will leave the details of the first four sections for your later study. The history and clinical procedures component of the OVA would consume 15 to 45 minutes. This would depend upon the complexity of the case presenting and whether the patient has been seen before.

The analysis section is the one that would get completely fouled up with Bill 60. I must read the analysis guideline word for word so that you understand the thinking process that accompanies the optometric eye examination.

The purpose of the analysis is the delineation of problems and the formulation of management plans. It reads, if you refer to the manual:

"(a) An analysis is expected of the history and data collected to determine the presence or absence of ocular health problems, refractive problems, and oculo-motor and sensory problems. A problem is defined as any deviation from the usual state, condition, structure or function.

"(b) Delineation of problems is expected at the highest level which the data and the member's knowledge and understanding permit. It may not be possible to define a problem as other than an unexplained symptom. At other times, a problem may be defined as a related collection of symptoms and/or findings. At the highest level of understanding, it may be possible to make a specific diagnosis of a disease, dysfunction, or disorder.

"(c) The development of a management plan for each defined problem is expected. Management is always expected to include counselling and, as needed, plans for further investigation, treatment or referral."

This is the "law" as it applies to optometrists. This manual is the standard against which ordinary optometrists are judged. It is not just our opinion of what we do for our patients; it is what under the present legislation we are legally obliged to do.

As you see in subsection (b), "it may be possible to make a specific diagnosis of a disease, dysfunction or disorder." We very often do. From subsection (c), you can see that the "management is always expected to include counselling."

Here are the problems:

1. Bill 60 would not permit the required diagnosis of a disease or disorder. It says I can only diagnose vision and oculo-motor dysfunctions. It is important; a dysfunction by definition describes a system that is anatomically and structurally normal but is not working or functioning properly. The diseases and disorders that we presently diagnose are not included in this definition.

2. The first authorized act would not permit the communication of a conclusion identifying a disease or disorder as the cause of a person's symptoms. It says I can only communicate a conclusion identifying a vision or oculo-motor dysfunction.

That, ladies and gentlemen, creates a ridiculous scenario. The best example of the situation created is one that you may have heard. A patient with cataract, which is easily diagnosable by any optometrist, would suddenly not be diagnosed. Cataract is not a vision or oculo-motor dysfunction. Cataract is a disease. Its diagnosis is made by a visual inspection of the crystalline lens of the eye using either an ophthalmoscope or a biomicroscope. We as optometrists diagnose cataract and then we assess its effect on the visual performance of our patients. We may refer this patient for treatment, ie, surgery, if the cataract is advanced. We would not refer this patient for a diagnosis.

Bill 60 as it stands would change what I do dramatically in this case. Since it is not a visual dysfunction and not an oculo-motor dysfunction, I could not diagnose it and could not communicate my diagnosis to my patient as I do now.

From reading sections 3 and 4 of Bill 60, it is clear that every condition that might be labelled as a disease or disorder must, if the patient is to be aware of it, be referred for medical consultation. That would triple the number of referrals -- all unnecessary, not to mention inconvenient and distressing to the patient and very expensive to the health care system.

Let me give you two other examples. Many people get a little yellowish bump on the white of their eye. It is a pinguecula, an innocuous disorder requiring no treatment other than a dose of reassurance. Again, this is not a vision or oculo-motor dysfunction, so therefore I would not be permitted to make that diagnosis or to provide the necessary reassurance.

Many of our contact-lens-wearing patients develop symptoms of itching and mucous discharge. These symptoms can be traced to wearing a contact lens with a protein deposit. This problem is diagnosed as an allergic disease known as giant papillary conjunctivitis. The treatment is removal of the lens or the film on it, which is always effective. Optometrists would be precluded from diagnosing this disease, from communicating their knowledge of it to the patient and from treating the problem by counselling on the appropriate action.

In conclusion, the authors of this bill cannot have understood the consequences of their writing. The scope-of-practice statement and the first authorized act in Bill 60 do not describe how optometry is practised in Ontario. Optometrists know what optometrists do. What optometrists do, they do responsibly. There has not been a single successful malpractice action brought against an optometrist in Ontario.

It is obvious to our group that the proposed scope of practice is grossly inaccurate. This error is a result of either a lack of knowledge of what optometrists do for their patients or it is an attempt by various groups to use this process here to narrow the scope of optometric practice. Either is totally unacceptable and I, and for my patients, hope this committee will recognize the serious flaw and ensure it is corrected.


Mr Beer: Thank you very much for this submission and the accompanying document because, again, in trying to determine precisely what it is you do, what you do today and what it is in your view you cannot do -- when the Ontario association appeared before the committee I was not able to be present. Are there specific recommendations around how you would see in Bill 60 the way the diagnosis is set out for you, what you can communicate? Are you saying you simply want to be able to communicate as it is set out in Bill 43, or that what is in your own bill should be expanded so it includes the kinds of examples like the cataract? Because clearly you are saying in paragraphs 1 and 2 of section 4 that it is limiting what you do today.

Dr Van Ymeren: Exactly. I think I understood your question. All we are saying is that presently we diagnose cataract and the legal interpretation of the -- I am not a lawyer, I am just an optometrist. I read the act and look at what I do in practice and say, "Geez, this doesn't allow me to do what I'm doing today."

Patients come to me for diagnosis. They do not want to wait for six to eight months to get in to see an ophthalmologist if in fact the diagnosis is totally within my ability, and it certainly is.

Mr Beer: So there may be other wording around what is in your own bill which would capture those other points?

Dr Van Ymeren: I do not think I could comment on that. My expertise or authority is that I know what we do and I know that --

Mr Beer: And that is not defined there.

Dr Van Ymeren: I think there are better people to suggest what in fact would better describe our scope.

Mr Hope: I have particular concerns that you indicated whoever wrote this did not know what they were talking about. I guess my question would be to the parliamentary assistant and legal counsel. How did we come up with it? We have an accusation of no involvement, or the authors did not know what they were talking about, and I would like a little clarification on this.

Mr Wessenger: With respect to that question, legal counsel is not here to specifically advise. However, it was based on the review. The legislation was based on the recommendations of the review, so I think you would have to even go back beyond the question of legal counsel in drafting, you would have to go back to what the review recommended. That would certainly be the assessment by the review as to what the areas of jurisdiction were. I might have ministry staff add to that.

Mr Burrows: As I explained previously, one of the things we have done since the receipt of the review's recommendations -- we know that the profession of optometry has concerns. Such things as the valuable service provided by the profession in screening, for example, in glaucoma and so forth go without question and no one is disputing those facts. In looking at options of potential wording, we have not been able to get agreement on what appropriate wording might be if there is something else that better describes what optometrists do.

Mrs Cunningham: I am going to ask the ultimate question. What do you think the appropriate process would be to come up with the appropriate wording that everyone does not seem to know should exist? I suggest you not say that you are not the one to come up with it.

Dr Van Ymeren: No, I can certainly tell you what I do today in practice and I can tell you that it is not well described, or it is not described at the present. Certainly we provide primary eye care to the majority of people in Ontario and that primary eye care involves diagnosis. It is not just screening. Screening would entail saying: "Yes, there is a disease; no, there is not a disease." I look at it and say: "It's a disease. Not to worry about it, we'll monitor it." I diagnose it and I communicate that to my patient. To suggest it is a screening is in fact an unbelievable oversimplification. It again illustrates, in my opinion, that nobody understands.

Dr White: I believe every patient who comes into our office expects a diagnosis. That diagnosis may be a tentative diagnosis, it may be an inconsequential diagnosis, but they expect a diagnosis. If we are not able to make that diagnosis, if we are not able to communicate that diagnosis, what are we doing?

Mr Martin: If in fact you are correct and we give you the benefit of the doubt here, my concern, coming from northern Ontario, is the delivery of service to the folks who live up there. Certainly, to limit your ability as optometrists to do your work in those areas where there are not the ophthalmologists would have a negative impact re access. Could you speak a bit about that?

Dr Van Ymeren: True, certainly there is more pressure on practitioners in smaller communities to service their patients more broadly, if you will. I practise in London and there are lots of ophthalmologists to refer to, yet I still make the diagnosis. The result of this would certainly affect your area more than London, I presume, just because you would be looking at an increased cost to the patients having to drive a long way to have an ophthalmological opinion.

It really just disrupts the normal relationship that practitioners have with their patients. Patients expect diagnosis, and to suddenly not allow that certainly is not the reason for the scope definition. It is supposedly status quo and it definitely is not. But I could see your concerns with regard to a small town.

The Chair: Mr Hope, you had one further question?

Mr Hope: When I am listening to the conversation, certainly the professions were involved in the -- what is it? -- the blueprint through the consultation process. I am sure the professions must have been involved through this discussion process. When I hear a presentation like this saying somebody does not know what they are talking about, are we talking about age differential between what the old fashion and the new fashion may be? That is why I am uncertain. I am hearing a presentation that we did not know what we are talking about.

Dr Van Ymeren: I gave you two options as to why this is like it is. I think it is maybe a combination of both, not just a lack of knowledge but in fact an attempt by groups to exploit this rewriting of the Health Disciplines Act to limit the scope of practice of optometry. Certainly that is understandable, considering the sources. I am sure ophthalmology is concerned with the broadening scopes of practice in the United States. In my opinion again -- I am just Joe Blow optometrist -- they are using this process to knock us down a notch to prevent further evolution. That is personally what I think is the cause.

Mrs Cunningham: You have got it. Can I just say something that may or may not be reassuring? I think what you have to do is carefully monitor the input from the Ontario Medical Association next week. Make certain your group is there. I would suggest they may even make some kind of a positive statement on your behalf if they feel so inclined. If they do not, you will know where you stand and where the lobby is coming from.

From a practical point of view, as a person who represents people who want service, I personally agree with what you are saying today. I think you should be prepared very quickly to get the wording you want. If you do not have somebody who can draft it, get somebody who can draft it and get it to Mr Wessenger so he will know exactly where you are coming from. In fairness to the ministry, it will then know what your expectations are. That is my advice.

Dr Van Ymeren: Thank you, Dianne.

The Chair: Thank you very much. We appreciate your appearing before the committee today. I know you realize that if there is additional information you wish to share with the committee, that you feel might be helpful to us, you can do that in writing at any time during our deliberations through our clerk.



The Chair: I call the London Regional Psychological Association.

Dr Ferrari: Thank you for allowing us to appear before you today to present our concerns.

My name is Dr Jack Ferrari. I am the vice-president of the London Regional Psychological Association and a staff psychologist at London Psychiatric Hospital. My colleague is Dr Bill Newby. He is the secretary of the association and the director of psychological services at St Joseph's Health Centre.

Before I begin our brief, I would like to mention that we are both involved in two other groups representing psychology. Dr Newby is a regional representative of the Ontario Chief Psychologists Association, and I am the president of the section on public service psychologists within the Ontario Psychological Association, both groups of which support the brief we are going to present today. In fact, our brief will essentially support the brief the OPA delivered yesterday.

The London Regional Psychological Association is a collegial association of over 80 practitioners, academics and students of psychology in London and the surrounding area. Most members are registered psychologists, doctoral graduates who are also registrants with the Ontario Board of Examiners in Psychology, the professional examining and licensing board since the passage of the Psychologists Registration Act of 1960, revised 1980. To be registered under existing legislation, individuals must have completed one year of post-doctoral training and have passed written and oral examinations covering general knowledge of psychology and principles of ethics and professional practice. Many of our members are also registrants with the Canadian register of health service providers in psychology. Such registration requires a minimum of two years of supervised practice or four years of post-doctoral experience in rendering health care services.

Our members occupy many different roles in health care and in other areas of professional practice in London and the surrounding areas. They provide direct clinical service to many kinds of hospital inpatients and outpatients, to clients of community agencies and through private practice. Our members' services include assessment and therapy for a variety of problems, including emotional disorders, chronic physical disorders such as pain, cancer and head injuries, substance abuse, infertility, sexual abuse, child custody and access as well as psychotic conditions. Many also perform administrative services in hospitals and are involved in community health care programs.

Psychologists are also involved in the training and education of other health care professionals in hospitals and schools in the London area, including those in such disciplines as medicine and nursing in addition to psychology. Members of our group are also active in areas outside what might be termed health care in even the broadest sense. We have members working within the educational system with the local school boards, acting as consultants to business and industry and within the criminal justice system, consulting for civil litigation and conducting client research not only within the health care system but within the community as a whole.

We fully support the introduction of the Regulated Health Professions Act, Bill 43, and the associated Psychology Act, Bill 63, with their goals of protection of the public and providing the public with freedom of choice of health care practitioners within a range of regulated professions. However, we wish to raise several areas of concern to the standing committee with Bill 63, the Psychology Act, as it is currently framed, and with section 26 of the proposed Regulated Health Professions Act. The concerns with Bill 63 are in the areas of title protection and the domain of service to individuals. Our concern with Bill 43 lies in section 26, dealing with diagnosis as a controlled act.

Finally, we support the retention of the doctoral degree as the educational requirement for registration as a psychologist, but we also recognize the concerns of master's-level practitioners. We would support a solution such as associate membership in the college for these individuals.

Title protection: Under the existing Psychologists Registration Act, the title "psychologist" and also the terms "psychological" and "psychology" are controlled. In other words, individuals cannot make use of these words in describing themselves or a service offered without falling under the terms of the act and being obliged to meet its requirements for professional practice.

Under the proposed Regulated Health Professions Act and section 15 of the accompanying Psychology Act, only the term "psychologist" will be covered. Under this draft legislation, an individual who is not a psychologist could offer, for example, a "psychological service" or "practice in psychology" and operate quite legally without being subject to any legal restraints upon his practice or without being subject to any disciplinary body for any acts of malfeasance or malpractice. Such an individual would not be required to be under the supervision of an individual who was covered under the Psychology Act and could practise without accountability under the act. We see no way in which members of the public could be expected to make the distinction between a psychologist who would be registered and regulated and a psychological therapist or counsellor in psychology who would not be regulated.

To promote the protection of of the public offered by the act, we urge that the terms "psychology" and "psychological" be controlled terms in addition to "psychologist" under section 15 of the proposed Psychology Act.

In a closely related matter, we are concerned about the restriction of the proposed Psychology Act, in section 15, to individuals "providing or offering to provide, in Ontario, health care to individuals." The proposed legislation does not define the term "health care," which leaves many of our members unsure as to whether some of their activities are covered by this act. For example, does a program dealing with assisting individuals to stop smoking come under the domain of health care? Does marital or family counselling or consultation on sexual dysfunctions come under the domain of health care?

If Bill 63 proceeds as proposed, we can see the only way of resolving these questions as being through expensive and time-consuming litigation after the fact. In addition, the practice of those members who provide services to industry, to educational systems, to the civil and criminal justice system and to private individuals whose problems may not fall under even the broadest definition of health care is not covered under the proposed legislation. This implies that such individuals could practise in the absence of any assurance to the public that their services are subject to minimal standards of practice or without legal recourse in the case of suspected abuse.

We can foresee a great deal of ensuing public confusion, in that many members of the public will undoubtedly find it extremely difficult to understand how some individuals can call themselves psychologists and be subject to a regulatory body and other individuals can also call themselves psychologists and have no such regulatory agency. It would seem to make much broader sense to ensure that all individuals wishing to call themselves psychologists or to provide a psychological service must be governed by a regulatory body, either through broadening the terms of the proposed legislation or through deleting the phrase "health care to individuals" from section 15 of the Psychology Act.

I will skip the rest of that section, as we are running a little short of time.

Our next concern is with diagnosis. Our members strongly support the provisions of the Regulated Health Professions Act, in subsection 26(2), to maintain diagnosis as a controlled act. Within hospital settings, the functions of assessment, diagnosis, treatment and consultation provide the primary areas of service for professional psychologists. We therefore favour the inclusion of diagnosis, as it is defined in subsection 26(2) of Bill 43, as a controlled act for psychology. Our members are strongly in favour of the principle of shared authority for controlled acts where those controlled acts are within the professional competence of the profession.

Our training includes an emphasis on the standardized objective assessment of individuals and groups that gives our discipline a unique perspective on individuals that is invaluable in assisting and providing a diagnosis. Psychologists have developed and use a wider variety of instruments to assist psychological diagnosis than do other professionals. We feel the provision of diagnosis is within the scope of professional practice in psychology. In supporting the retention of diagnosis as a controlled act for psychology, we do not mean to exclude other practitioners either from assessing for purposes of treatment or from regulated diagnosis within their scope of practice.


Finally, on professional entry, under the current legislation entry into the profession of psychology requires a doctoral degree in psychology, as well as one year of post-doctoral supervision and the successful completion of written and oral examinations. Through the course of the health disciplines review, arguments have been made for an alternative route to registration. Our members are familiar with the general trend throughout North America to converge upon the doctoral degree as the criterion for entry into professional practice in psychology. We support the retention of the doctoral degree as a requirement for professional practice in psychology. At the same time, our members work on a daily basis with other professionals within psychology who do not have a doctoral degree and who provide high levels of professional service. There is substantial agreement that an associate membership would not be inappropriate and would provide professional recognition for individuals without a doctoral degree in psychology. Thus, many members do favour the establishment of associate standing under the Psychology Act which would provide professional recognition and standing for individuals without a doctoral degree. Thank you.

Mrs Cunningham: I actually have a couple of questions here, if you can get them all on the record at once. First, I would like you to enlighten the committee with regard to the letter of agreement of the three associations. I am wondering if you in fact agree with the letter of agreement. I have a personal concern, given that I am aware this government is anxious to get this legislation through. My understanding is that your letter of agreement is for 18 months. So if you have to ask us questions, this is the appropriate time.

The second concern I have is about the title protection. I am asking you why you think the title protection was drafted the way it is in this current legislation, because it is very controversial within the London community. I would like your opinion on that.

The third point is that some of the groups that have come before the committee, just looking at some of the briefs, feel that only medical diagnosis should be a licensed act. Perhaps you would like to take this opportunity to respond to those groups that make that statement.

Dr Newby: Let me try to make a beginning, if I remember the questions as we go through. Our reaction to the letter of agreement, which we saw only this morning, has been quite positive. We are very pleased that we have this opportunity to strike some agreement with the presently unregulated health care professionals. It was not until you mentioned the 18-month time frame, though, that it caused me some concern, in that it was my assumption, in reading the letter of agreement, that it would not necessarily hold up legislation. I hope that is the case. Perhaps the question I do have for this committee is, what do we know about the time frame for putting this legislation through? Would the negotiations that the letter of agreement discusses in any way impede legislation?

Mr Wessenger: With respect to the matter of the time frame of the legislation, I really am not in a position to give you a determination on that, but with respect to the second point, I do not see your letter of agreement in any way impeding this legislation. We are very pleased we have this letter of agreement and we are pleased this action is being taken to try to resolve the matters.

Mrs Cunningham: There are another two issues.

The Chair: The other questions that were asked by Mrs Cunningham? You do not have to answer if you do not want to.

Dr Newby: I would be pleased to. Since these questions do concern the points we have raised, I would certainly be glad to do anything we can do to clarify them. I think the second question was, why was title protection legislation drafted as it was? It is a difficult question to answer from this perspective, but I infer that the rationale for the legislation being drafted as it was is that it is desirable to have some homogeneity of wording and regulation across the different professions. I certainly agree this is the case.

I think what we are arguing, though, is that in the case of the title protection legislation with respect to psychologists, the one-size-fits-all approach does not work so well. We have articulated two reasons we believe that to be the case.

I chanced this morning on this document Better Protection and More Choice in Health Care, in which the question is posed, "How can I tell the difference between regulated professionals and other health care providers?" The answer with respect to psychology is: "Only a qualified psychologist can claim to be `a psychologist.' Anyone who is not a member of a regulated profession and uses the title can be charged and fined" and so on. I am very supportive of that. It is what we would like and it is what would protect the public. I am not convinced that the way the legislation is drafted, that is what the legislation says. For example, someone working in a school board who falls outside the purview of providing health services to individuals presumably could call himself a psychologist without being regulated. So we support broadening the regulation to all those who can call themselves psychologists, thereby providing better protection for the public.

Similarly, I think the public would reasonably expect somebody providing psychological services, as we articulated in our presentation, also to be regulated. This is consistent with the findings of the Environics poll that OPA had commissioned. That poll tells us that the public expects somebody delivering psychological services to be regulated. I infer from it that the public then would wish it. That is an inference.

Mr Hope: My question is still around this area, because I have been reading this over and over and shaking my head sometimes. When I look at this part of the MA versus the PhD level, who has the more grass-roots, on-the-job training, I guess you could say, because things change day to day, is the MA more than the PhD level. Then I am looking at this. You are looking at this government to put it into legislation. You say there is a temporary, 18-month -- I am saying, why can the MAs and the PhDs not get themselves together so that you are not forcing the MAs to --

Dr Newby: I sincerely hope we can get them together. I assume the letter of agreement is an article of faith to the effect that we can. I am not sure why you are saying an MA would have more training and experience when a PhD in fact has 10 years' worth of training.

Mr Hope: Well, 10 years of the schooling, academic level of it versus on-the-job and being on the front. I am not a professional of the field, but I am saying, who is the one who is dealing with the public on a day-to-day structural basis? In my own mind, I think the person who is dealing with the public day to day would have that.

Dr Ferrari: Excuse me, but I really want to respond to that. A PhD has an MA. You get an MA and then you get a PhD, so I do not understand how an MA would have more training in any sense. An MA who goes out to work with his MA will get on-the-job training; so will a PhD. I have a PhD. I work with the London Psychiatric Hospital. I have been working there for almost six years. Before that, I worked at St Thomas Psychiatric Hospital for 11 years, front line, on the job. Many of my colleagues are in the same position. It has nothing to do with the degree. Somebody with a BA can go and work in a hospital and get front-line training.

The Chair: I have a question from Mr Beer.

Mr Beer: My question has been answered, thank you.

Mr J. Wilson: I really have a question for the parliamentary assistant. If a person is accepted as a member of the college, does he not fall under the full effect of the act, no matter what setting he is in, whether educational or institutional? Maybe that would clear up this thing. This keeps appearing in briefs.

Mr Wessenger: Maybe I better refer that to ministry staff.

Mrs Cunningham: Oh, come on, Paul, you could have done that one.

Mr Burrows: As a member of a professional college, you are responsible if you are practising the profession. It is not site-specific; you practise the profession, period.

Mr J. Wilson: I did not understand that. If you are accepted as a member of the College of Psychologists of Ontario, you are deemed to be a psychologist under this act?

Mr Burrows: Yes.

Mr J. Wilson: You have title protection. Just trying to get some understanding of the "delivery of health services," that phrase, would not a psychologist be a psychologist be a psychologist, whether in an educational or other institutional setting?

Mr Burrows: I certainly do not purport to be an expert on psychology, but it is our understanding that there is a small percentage -- I believe we have correspondence something to the effect that 8% practise in settings other than health care settings; for example, providing advice as an industrial psychologist about the colour of walls and the effect that will have on people's attitude at work sort of thing. So there are certain activities, according to the information that we have been provided, where it would be pretty farfetched to consider that they really are in the sphere of health care.


Mr J. Wilson: Just along this line, the answer from the ministry to the witnesses who have raised this point before has always been they are not really, as you have just said, delivering a health care service, so they do not fall under this act. But maybe the corollary would be, does that mean they are entitled to join the College of Psychologists of Ontario?

Mr Burrows: It is possible to be a member of a college and not practise actively in the area. For example, I am a member of the Ontario College of Pharmacists, but I do not actively practise pharmacy.

The Chair: But if you did.

Mr Burrows: But if I did, then I would be accountable to the college for my performance and behaviour.

Dr Newby: And further, would not be required to register with the college. I am sorry I am speaking out of turn.

Mrs Cunningham: But just in clarification, the majority of psychologists are not in the health care professions, I would guess, at all. I am not arguing because you are guessing and I am guessing, but my view is that the majority of psychologists are not in health care. I mean, has anybody ever added it up? You are the professionals --

Dr Ferrari: Yes, they have, and they come up with that 8% figure by defining health care or related areas in a certain way.

Mrs Cunningham: Well, that is the issue, is it not?

Dr Ferrari: If you define it more narrowly, then probably the minority of psychologists are in health care.

Dr Newby: It is hard to do in the absence of that definition.

Mrs Cunningham: Exactly.

Mr J. Wilson: But in this act, though, you are saying the problem would be solved if everyone was required to register with the college in no matter what setting they are delivering psychological services?

Dr Ferrari: Yes, that is the way it is right now, in fact.

Dr Newby: That would not bring them under the regulatory umbrella, because the regulatory umbrella, as I understand it, refers to those who are engaged in the delivery of health care. So the problem of protecting the public I do not think would be solved except internally within psychology.

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

Just to clarify, and if I am incorrect I know that the ministry officials will correct this, it is my understanding as a statement of fact that anyone who qualifies with any college's role regarding entry to practice can apply to the college to join and be a member of the college, and it is then up to the college to determine whether or not that individual meets the entry requirements as that professional.

Mr J. Wilson: No, I understand that, but when they are appealed, what act do you fall under? If you are delivering --

The Chair: This legislation covers an individual, it is my understanding, who is delivering a health service, health care, and it is not site-specific. That is how I understand the interpretation, and Hansard will note that the two people on my left have said that is correct.

Mr J. Wilson: Well, I understand that, but the committee is grappling with those in other settings, given the lack of definition of health care.

The Chair: Okay, but we may want some time to discuss this further, and you will have that opportunity at least on the 16th and 17th of September if not before then.


The Chair: I would like to call now the Ontario Association of Social Work Administrators in Health Facilities. Please come forward, introduce yourselves to the committee. You have 20 minutes for your presentation, and if you leave a few minutes for questions we would appreciate it. Please begin now.

Mr Pretti: First of all, thank you very much for the opportunity to meet with you and to present our views. My name is John Pretti. I am manager of social work at University Hospital. With me is my colleague Anne Sawarna, who is director of social work at the London Regional Cancer Clinic.

We are speaking on behalf of the Ontario Association of Social Work Administrators in Health Facilities, and we represent more than 1,000 front-line clinical social workers in hospitals. In addition, there are approximately another 1,000 social workers employed in a variety of mental health and other programs that are related to hospitals or that are based in the community. So as managers we are directly both administratively and clinically responsible for those social workers.

Let me talk a little bit about what we do as social workers. I will restrict my comments to social workers in health care. Similar to psychology, you probably know social workers are involved in many other settings, education, addictions field, corrections, etc, but I will restrict my comments to the health care field.

It is estimated that approximately 40% of patients in acute care hospitals have psychosocial problems which may affect their recovery, their utilization of health care or their return to the community. Social workers are front-line health care providers who deal with and respond to the emotional, the mental, marital, family difficulties that are related to health care, to illness, to recovery. In that sense, we as social workers deal with a variety of personal and family difficulties that are often exacerbated by illness, by hospitalization, and often these individuals are most vulnerable in society.

Overall, we as an association strongly support and are supportive of the proposed legislation, particularly since it addressed such important issues as protection of the public, recognition of consumer choice and it provides a common mechanism for regulation of the health care professions. There are, however, three areas which I want to discuss where we have major concerns which we hope this committee will address.

First of all, and many of you know this already, social work is absent from this legislation. In my view, it should have been included under this legislation, but it is not for a number of reasons. We now have a circumstance in Ontario; this is the only province that has no governing body for professional social work, and when this legislation passes, social work will be the only unregulated profession in the health care field. We have well over 2,500 university-trained professional social workers working not only in hospitals but in a variety of addiction centres, community-based family practice units, mental health clinics, psychiatric hospitals, etc.

We, the social workers in the province, have taken the initiative. We have a voluntary college. There are two things I think this committee can do. One, it can make a recommendation to urge this government to provide some form of regulation for the practice of social work in the province, either within or outside of this act.

The second area I want to discuss, and that is the area I want to focus on primarily, is our concern with the diagnosis clause or section 26. We urge you to consider this very, very closely. If you will look at page 5 for a moment -- I know time is limited -- let me give the illustration at the bottom of page 5 of a scenario that might involve a 67-year-old man with liver cancer referred by the oncologist to the social worker for an assessment.

The patient's daughter stated to the physician that her father was having difficulties coping with his illness and appeared to be depressed. Upon receiving the referral, the social worker saw the patient and was able to observe the neurovegetative symptoms of depression and the fact that the patient was quite withdrawn.

As part of the assessment and diagnosis, the social worker interviewed the patient's 40-year-old daughter who also confirmed marked confusion on the part of her father, a marked confusion that is not normally related to straightforward depression. The daughter confirmed that her father had attempted to put on his coat but mistakenly had chosen his wife's coat and could not determine the problem with the fit. A daily churchgoer, the patient could not remember the directions to the church, which also substantiated significant cognitive deficits.

Now, in this example the social worker was able to assess or diagnose that this depression, this withdrawal, was not related to normal grief or reaction depression but related to organic factors. Again, you could see how difficult it would be or how impossible for us to practise in our daily routine if we were not able to discuss the implications and the meanings of this "illness" with the patient, or in this case, the patient's daughter, as well as the oncologist.


Social workers, like others, work in health care teams and have responsibility for communicating the diagnosis, the implications. Of course, the diagnosis forms the basis of a therapy or treatment plan. I urge the committee to either remove this section from the act or provide provisions which would clearly exempt social work from the possibility of being subject to -- in fact, the social worker would be at risk of being prosecuted for carrying out what we see as normal practice in our day-to-day work.

I move on quickly to the last section. The last point I want to make is the harm clause. Generally speaking, we support the fact that this committee has dropped it; we hope you will not reintroduce it in some form. It lacked quality. We, as an association, have in fact expanded our comments in this area.

One last point which is not in the brief: Section 30 does restrict the use of the title "doctor" to five professional groups. I have several colleagues in clinical social work who have PhDs from universities in Ontario, like Wilfrid Laurier University, the University of Toronto in clinical social work. I think recognizing the PhDs of others and not of social workers practising in health care, would really result in an atmosphere of inequity. I hope this committee would reconsider this exclusion and allow social workers who have a doctoral degree to use this title.

Just in summary, we would ask that you consider, first, incorporating social workers in this act and, if that is not possible, to make a strong recommendation that this government act to provide us with separate regulation -- in fact, the previous government had committed itself to enacting social work regulation;

Second, modifying the diagnosis clause so as not to restrict the services of hospital patients and other health care clients. Again, I want to emphasize how important that is in this community and I am sure in other parts of the province. People need mental health services, marital and family therapy, and to further restrict -- I think that would be the effect. Maintaining this clause the way it is written would certainly not do justice to these vulnerable people in society.

Third, we would ask that you not reconsider the harm clause.

Mr Owens: Each time an unregulated practitioner brings the question of the diagnosis clause forward, I find myself struggling and trying to determine exactly why you folks find it problematic. I am wondering if it is around the usage of the word "dysfunction," which tends to be more within the realm of a condition -- I am even trying to pick my words carefully -- that you would identify rather than a disease or a disorder.

In your example of working on the oncology floor, do you actually feel that you are diagnosing or communicating that diagnosis to the patient rather than perhaps in a supportive role of the oncologist?

Mr Pretti: I can answer that. Yes, I do feel we are diagnosing. Perhaps a better example is in the mental health fields. For example, if I see a couple referred for therapy, perhaps initially the wife appeared in the mental health clinic with mild to moderate depression. When I or my staff see the couple for assessment, certainly in a mental health context that relationship in many respects is very dysfunctional. Yes, a diagnosis is used.

In fact, we use, as probably many of you know, the criteria in the DSM III in the mental health field and use them to diagnose and to communicate, in this case to the couple, our observations. As well, in the pursuing of therapy, we would hopefully engage the couple in correcting or altering various dysfunctional aspects in their relationship.

Mrs Cunningham: I will hit another area. I am wondering, perhaps for clarification not only for yourselves but for the committee as well, if someone here can enlighten us as to the first request here in the summary, and that is either a social work act which we thought was almost ready or the inclusion here under this bill. Madam Chair, I do not know who you want to refer that to, but I certainly think we should hear it now.

Mr Wessenger: I do not think really I can answer that question with respect to the social workers' act because it is really not within the framework of our ministry, but maybe ministry staff could clarify further.

Mr Burrows: The Ministry of Community and Social Services remains the lead on the issue of the regulation of social workers. You may recall that in the early years of the review there was a decision that social workers more appropriately would be regulated under that area. There was some form of agreement that this would be the chosen path. Since that time I understand that the groups who speak on behalf of the social work profession at the provincial level have been working with that ministry.

As far as I know, those discussions are still ongoing. We have heard some evidence at committee along those lines to indicate that the discussion is occurring. I believe the Ontario Association of Professional Social Workers is on record in Hansard with respect to its position on the matter, which I think is consistent with that approach continuing. I think it is fair to say that we have also heard that the options you have put forward have been expressed by other social work representatives as well.

But for now, our ministry, Health, does not have government policy approval to be the lead on this issue. We would not see social work being under this particular umbrella, at least at this time.

Mr Pretti: I hope you realize that we are left in jeopardy in the meantime if this act passes and we are left literally unprotected in terms of providing health services.

Mrs Cunningham: Mr Pretti, it is my understanding that the Ministry of Community and Social Services representatives will come before this committee before final deliberations are made. It is my understanding that this request has been put to the ministry. If we do not think there is movement, because some of us have been waiting for a very long time, then perhaps the committee will proceed to make some amendments to this legislation as it sits. Certainly that is the intention we have in our caucus.



Ms Johnson: Good afternoon. My name is Edythe Johnson, and I have with me Erica Brophy and Linda Hearn from the London Birth Centre Committee. Brad Keeler on your list was to be with us and got called out. He has asked me to read his presentation. I will do that for him and I will attempt to entertain questions upon his presentation to the best of my limited ability.

The London Birth Centre is a group that consists of a strong, consumer-driven core and a very broadly based, interrelated professional board of advisers, working together to bring a birth centre, freestanding, to London, we hope in the near future.

First I will begin by reading Brad's presentation. Brad Keeler is one of our advisers and he is involved in health care consultant work. He would like to address four major points: acceptability and accountability, continuity, quality and cost. They must all work together if the new disciplines are to work to the benefit of the patients and the taxpayer. If the patient has no choice of provider, that is, only a physician and only a hospital, then her accountability for following advice in the final outcome is reduced. Allowing the patient to choose from among providers has the potential to increase patient responsibility, a major benefit to the system.

I am concerned about self-discipline versus public accountability. Please ensure strong consumer, male and female, representation on committees. Perhaps the public should own the professions. This could be reinforced by 51% consumer membership. Perhaps it could be moderated if a two-thirds vote was required to adopt motions for both the colleges and the complaints and disciplines committee.

Consumers should have a stronger voice if they are to be respected and empowered and their wishes to be reflected. Why not link complaints and disciplines together? It seems like a duplication of effort, creates the potential for mistakes and lengthens the adjudication process. The jury who hears the case should determine the penalty. Ensure that the link between physician, midwife, birthing centre and hospital is transparent to the patient. Increased complexity should not increase confusion for the patient. The temporary or permanent transfer of care from one provider institution to another must be easy. Interprovider links should be formalized in the legislation. It should not take more than a decade to shift responsibilities between professions in the future as technology changes, which the current legislation has taken.

Allow midwives to perform tasks based on technical competence and ability, rather than based on the desire of another profession to restrict service providers. An example is intravenous reinsertion for rehydration.

I am concerned about grandmothering. The standards being developed for midwives seem to be a model for other new disciplines and for foreign graduates wishing to practise in Ontario. There is no comment about setting educational programs. Although it is not specifically part of the act, it is very important. It is essential to ensure quality of care.

In terms of cost, support midwives as primary care givers. Enable them to function parallel to existing systems. Cheap teaching hospitals receive an average of $1,750 per normal birth, excluding the cost of the obstetrician-gynecologist and general practitioner. In the US midwives are funded as individual providers, along with doctors, at a percentage of the fee paid to the physician. I do not support piecework fees, but ensuring that we get value for our dollar is important. To control costs, attach midwives to birthing centres or to hospitals prior to funding support.

This is respectfully submitted by Brad Keeler.

Ms Brophy: My name is Erica Brophy and I am a member of the London Birth Centre Committee. I support this legislation and the legislation that would fully recognize and register midwives in Ontario.

I used the support of a midwife for my labour and the birth of my daughter in June of 1990. I also drove an hour and a half from Dresden to London to partake of this service. The support I received from my midwife made it possible for me to remain at my parents' home in London during my labour for all but the last hour before my daughter's birth. This was important to me because when we were in my parents' home my husband and I felt we had more control over what happened during the labour and we could more easily avoid unwanted interventions. I also feel that I was more relaxed in the home setting than I would have been in the hospital and therefore my labour progressed more easily and perhaps quicker than if I was tense and uncomfortable.

I was very pleased with my labour and delivery except for two things. The first was that moving from my parents' home to the hospital in the very late stages of labour was not the most comfortable experience, and it would have been unnecessary if a birth centre had been available. The second drawback to having my daughter in hospital was that she was taken away from my husband and myself to go to the nursery. We would have preferred to have her stay with us the whole time, and this will be the policy of the London Birth Centre.

My husband and I did not feel comfortable having a home birth for our first child in case something were to go wrong. Unfortunately, there presently is nothing in between hospital births and home births. A birthing centre would fill this gap. My husband and I have discussed the options and we have decided that when we have our second child we want the right to the birth of our choice, and that would be in a birthing centre.

Accessibility to midwife care should be available to all women regardless of their risk category. The support and continuity of care a midwife can offer, which a physician often does not have the time for, is especially important to a woman undergoing a high-risk pregnancy and delivery. Having someone the woman has developed a relationship with over a number of months present at a high-risk birth can help reduce the mother's stress and can make her feel better about all the different procedures that are performed on her. Some mothers would even like to have their midwives present during the Caesarean sections, if they are given a general anaesthetic, so that she can describe what occurred during the birth to the mother later and also so that she can be there for their child and make sure that baby gets to meet dad and the rest of the family as soon as possible.

Sometimes a very normal pregnancy develops indications of a possible problem during labour. Midwives will immediately transport the mother to a hospital to have the backup equipment and expertise in case a problem does develop. Often no problem does develop and a normal birth ensues.

Midwives should be able to remain as the mother's primary care giver during the transport to the hospital and at the hospital until it becomes apparent that there is a real problem and the expertise of another professional is needed. Even at this time the midwife should be allowed to remain with the mother in a supportive role. When a birth starts to go wrong the mother still requires as much, or more, support. Having her midwife with her will continue to give the mother the emotional support she needs and will help her to feel more positive about the lack of the normal delivery she had hoped for. This continuity of care can also help the mother and her child after they return home from the hospital. Mothers who have had a difficult birth may be very nervous about the wellbeing of their child, but having someone they have developed a relationship with, who was also present at their child's birth, to ask questions of would help to alleviate their fears. I strongly recommend that this committee ensure that the legislation facilitates continuity of care.

Midwives have an important role to fulfil in our society. However, at present there are far too few of them and they are really only accessible to the fairly well-off. If this act and the Midwifery Act are both passed, midwives will become available to anyone who wants one and midwifery will become a more enticing profession for others to train for. Birthing centres will also become the perfect training centres for new midwives and a perfect middle ground for women who want to have a non-hospital birth with a midwife but are nervous about having a home birth.

We support and applaud this government's innovative approach to health care through this legislation. We also ask you to be attentive to the ways in which this legislation can continue to enable professional autonomy for midwifery.

The Chair: Thank you for an excellent presentation. Are you finished?

Ms Johnson: No, there is one more piece, and I will be presenting that. As I said, I am Edythe Johnson and I am the past president of the Association of Ontario Midwives and currently the Canadian co-ordinator of the Canadian Confederation of Midwives, but today I am speaking on behalf of the London Birth Centre.

This legislation leads us to a more open, consumer-responsive and publicly accountable health care system through open public hearings, increased public membership on councils, greater public input to policy decisions through the Health Professions Regulatory Advisory Council, and recognizing new disciplines, thereby increasing choice for the consumer and enhancing the opportunity for alternative approaches to effective health care. It has my full support.

The comments I wish to make are specific to Bill 56. To ensure that the proposed scope of practice for midwives as primary care givers is enabled and to ensure continuity of care can be provided by midwives, I support the draft amendments submitted by the Minister of Health to this committee, those being the ability to perform heel pricks, insertion of urinary catheters and the ability to prescribe certain drugs as specified in legislation; and those requested by the Association of Ontario Midwives, those being the ability to do prenatal blood screening, insertion of intravenous catheter for the purpose of rehydration and dispensing specific medications in specific post-partum situations.

The introduction of the profession of midwifery into the health care system will provide childbearing women with the physiologic model of care that is quite different from the existing medical model. It is important to give thought to how best to maximize the full benefits midwifery has to offer our public.

Autonomous, freestanding, community-based birth centres will provide a home base for midwifery practice that facilitates the focus on birth as normal. The level ground a freestanding birth centre provides will allow for the greatest opportunity for balanced interprofessional relationships and cross-education of other professionals, impacting other disciplines and settings through the experience of a healthy comparative to what currently exists within the system.

Many consumers of midwifery care have, for some time, expressed a desire for an alternative location to give birth. Currently women have only the choice of hospital or home in which to give birth. A freestanding birth centre provides the community-based and community-responsive environment for a large number of women who need a middle-road option in regard to the place of birth.

The integration of midwives and the implementation of freestanding birth centres together, simultaneously, is essential to best maintain and continue to develop optimal vitality within the profession of midwifery, so that the full spectrum of benefits of midwifery care will be enjoyed by consumers, our communities and our health care system. Thank you.


Ms Haeck: I would like to address some of Mr Keeler's concerns. It relates to a presentation we had earlier. Ms Johnson, I believe you were present in the audience. With Mr Keeler not being here, I understand that possibly you could carry this back to him.

Ms Johnson: I will do that.

Ms Haeck: In relation to when the colleges are set up, it is my understanding that the colleges will be determining who qualifies to practise within the province, so that they will be looking at whether or not, as one of the earlier presenters outlined, there will be foreign qualified midwives accepted. It definitely will be something I would assume the College of Midwifery will be looking at, and they will be preparing the regulations for those qualifications.

To further address one point under "acceptability and accountability," it has been a proposal for this piece of legislation that the consumers make up just under 50% of public representation on the quality assurance committees. I guess my question is why Mr Keeler would like to see it at 51% as opposed to, say, 45% or 48%, whether there really is that much of a difference, in light of the fact that other midwives or people who have been supportive of midwifery have felt that people on the committee should have a good understanding of midwifery before they are appointed to those positions.

Ms Johnson: Are you asking me to address that or to take that back to Mr Keeler?

Ms Haeck: Just take that back to him, if you would.

The Chair: And inform him as well that he can communicate with our committee in writing in response to Ms Haeck's questions, if you would, please.

Mrs Cunningham: I am just wondering whether you have discussed the qualifications. It certainly seems to be something that has been raised as a concern before our committee. I am wondering whether you have had any internal discussions, or just what your ideas on that issue would be.

Ms Johnson: In terms of the London Birth Centre and qualifications of midwifery?

Mrs Cunningham: No, of midwives.

Ms Johnson: In the association. The London Birth Centre is in agreement, thus far, with the Association of Ontario Midwives and the Interim Regulatory Council on Midwifery. As part of their process, the interim council is looking at standards and scope of practice and regulatory tools that will ensure a high level of training and ongoing competence for midwives.

As part of the government's impetus to bring about midwifery in the province, it appointed a midwifery implementation planning project recently, which has made recommendations to the minister that will ensure current practitioners are integrated into the health care system in such a way that we have a baseline of competence that is acceptable to the public and other professionals as well as midwifery.

I believe it was Mrs Caplan who referred to it earlier. This pre-registration program will have baseline eligibility criteria that have been developed before admittance, and then probably at least six months to one or two years of process to bring everyone up to a level all of us can feel competent and confident with. At that point registration and licensing will be provided, but not a degree. In terms of overall qualification for midwifery, a four-year bachelor of science in midwifery has been recommended thus far, and supported by both our association and by the London Birth Centre Committee members as the route to go.

Mr Beer: I am interested in the point you make at the end of your submission about the integration of midwives and the freestanding birth centres, and that was also reflected in the submission by Mr Keeler. Could you expand a bit on that? Are you saying that midwives could practise independently, but as part of setting up a birth centre you would want to have midwives permanently assigned to those? What do you mean by "integration"?

Ms Johnson: Sites of practice are still under discussion for midwives, but we do see that the maximum benefit of midwifery care would be enjoyed by allowing various settings for practice. As I said, currently you can have a home birth, which is not entirely isolated but more isolated than a supported environment, and therefore only certain people would be considered a safe risk for that, and only certain people would choose that; you can have a hospital birth that is governed by the medical model and other professions; and more and more it is seen that this middle-road option of a birth centre, that is based on the care delivery it would provide, based on the physiological, normal perspective of birth and staffed by midwives, and also available to family doctors who choose to work with it and are philosophically in agreement, would give a home ground.

Mr Beer: But the main point is that midwives would be the primary health care providers there?

Ms Johnson: I think that would depend on the community. These are community-based, community-governed, consumer-driven and -directed.

Mr Winninger: There has been a concern expressed regarding the role of the midwife as primary care giver in a hospital setting vis-à-vis, say, the lead nurse in the delivery room, a question of whether authority would be shared or who would be subservient to whom. I wonder whether you could comment on that.

Ms Johnson: I can comment on it as one midwife who has worked in the hospital setting over several years, and also in terms of reflecting for my association that we are most interested in working co-operatively with nurses. Midwifery needs to be primary care as a functional profession in order to deliver continuity of care and to deliver as much as midwifery can to its clients and to women. To restrict the ability of midwives to care for their clients would not be wise. At the same time, we do not support a hierarchical system of care delivery, and so we are most interested in working co-operatively with nurses and do not see that there would be a reduction in the importance of a nurse's role overall.



The Chair: I call next the Midwifery Task Force of Ontario, London chapter.

Ms Haffie: Thank you. The Midwifery Task Force of Ontario is a not-for-profit, consumer-based organization that has been working toward the recognition and legalization of midwifery since 1983. Much of our work has been launched from the kitchen table or over telephones with extended cords that allow us to kiss spouses, wipe noses and prepare dinners while educating, lobbying and fund-raising from Thunder Bay to Cornwall to Windsor.

The MTFL -- and I will not throw any more acronyms at you, that is the only one -- is one of 17 chapter groups across the province. I am Sue Haffie. I am the local co-ordinator of MTFL and the president-elect of the Midwifery Task Force of Ontario. With me is Michele Girash Bevan. Michele is a member of the local chapter and the regional representative for southwestern Ontario. We are delighted to be here and welcome the opportunity to speak to you on behalf of the women and their families from the London area, who make up our chapter.

London's only practising member of the Association of Ontario Midwives served our community for over seven years. She offered a unique quality of service to birthing families. Unfortunately, she is currently on medical leave and we are now faced with travelling to access midwifery care.

We look forward to legislation to improve access to the benefits of midwifery care in our community and all communities in Ontario. We offer our support of the overall intent of the Regulated Health Professions Act and, in particular, the Midwifery Act. Bill 56 establishes midwifery as an autonomous profession, provides more choices in care givers, makes midwifery a financially feasible option and allows for community-based health care which will lead to more preventive health care versus crisis intervention.

Ontario midwifery has come to be because women have insisted on an alternative to the care being offered to them that would recognize the importance of three main principles of midwifery care. One is continuity of care. This involves regular 30- to 60-minute pre- and post-natal visits with one or two primary care givers with whom the birthing family has developed a long-term relationship. It is knowing that a knowledgeable, trusted care giver will be there to offer safe and effective care. Second is informed choice. Midwives recognize women as decision-makers. They offer education and support to empower women to make responsible, informed decisions about their own health care. Third is choice of birthplace. Midwives and their clients recognize that home, freestanding birth centres, hospital-affiliated birth centres and hospitals may all be safe and appropriate places to give birth.

Ms Bevan: I would like to focus on one of those criteria, and that is continuity of care. Again, to us continuity of care means maintaining a health care relationship with a carefully chosen care giver throughout the pregnant year; in essence, finding a face you trust and seeing that face at every pre-natal visit, through labour and birth and at post-natal visits. Midwifery care provides continuity of care. It recognizes that continuity is necessary for a healthy, safe birth.

The Midwifery Act, as written, defines the scope of practice as "the assessment and monitoring of women during pregnancy, labour and the post partum period and of their newborn babies, the provision of care during normal pregnancy, labour and post partum period and the conducting of spontaneous normal vaginal deliveries." We are concerned about the use of the word "normal" here. What is normal and who is to decide what normal is?

Historically, midwives and medical practitioners have differed on their definition of "normal." Midwives believe that birth is a normal physiological process. Midwifery philosophy maximizes normalcy and dissuades intervention. On the other hand, some obstetricians may view the birth canal as a dangerous place for the baby-to-be. There is a quote of physicians saying, "Birth is only normal in retrospect." Obviously these two views are not in agreement. In order for midwives to be an autonomous body, we feel it is necessary to have an independent definition of "normal," otherwise women may be caught in the middle of a dispute between midwifery and medicine.

There are a couple of examples that might help to illustrate my point. On a personal level, I have had one previous caesarean section. According to the Association of Ontario Midwives' guidelines to the scope of practice, if I have a healthy pregnancy with my next child I will be considered normal. According to many medical practitioners, however, I am a high risk and would not be considered a candidate for midwifery care. The two views do not agree.

As another example, one of our members experienced high blood pressure in her first pregnancy and labour. She was induced at 38 weeks. Induction of labour may have a place in some cases, but in many instances it is associated with an increased risk of further intervention, of forceps delivery, of C-section, etc. In her second pregnancy Beth acquired midwifery care. Again she had high blood pressure. According to some medical practitioners, she could have then been considered high risk and not a candidate for midwifery care. Her midwife prescribed a special diet, her blood pressure came down and she had a healthy home birth. Again in this situation, where midwifery philosophy maximizes normalcy, medical philosophy would emphasize illness. We need to be assured that women in this kind of situation will still have access to midwifery care.

The Interim Regulatory Council on Midwifery has spent a great deal of time developing mandatory guidelines for consultation and transfer of care. We have appendixed our submission on to this document for your consideration, and we hope that "normal," as used in Bill 56, will be in keeping with the recommendations in this document.

Also as written, Bill 56 describes the scope of practice for midwives, as I said, in regard to normal pregnancy and birth. We would like to ask this committee if this means that those women who are assessed as being high risk, where there is no question that they are high risk for whatever reason and therefore are under the primary care of a physician, will still be able to access midwifery care in a supportive role.

When we choose care givers, we tend to pick them on the basis of competence, common philosophy and personal compatibility. To put it simply, when I choose a midwife I will choose her because I trust her and I feel safe with her as my care giver. Pregnancy is a time of great emotional upheaval. There is lots of excitement, lots of anticipation, but there is also anxiety. If I find a care giver who can make me feel safe, that can reduce much of that anxiety and lead to a better and healthier pregnancy and birth.

If, however, I fall into a high-risk category, I still need that trust and safety and continuity even more. If I have those birth plans destroyed, if I have to deal with strangers I do not know and do not necessarily trust, then anxiety takes over, and anxiety can be disastrous in pregnancy and birth. If I can retain the services of my midwife for emotional and psychosocial support, to keep my birth as normal as possible in that high-risk situation, to prevent that cycle of intervention that is all too common in high-risk pregnancies, then much trauma can be avoided. In such a case, the midwife can be a counsellor, an advocate of normalcy and a knowledgeable source of information. She can still provide that familiar face, that continuity of care, throughout the birth and the post-partum period.

Ms Haffie: Consider the women who has a caesarean under general anaesthetic. Her partner is not permitted to be with her. Part of their birth experience is blocked out. That part is missing. Midwives who have been permitted into the OR play an important role in filling in that gap. They can relate all of the details of that missing part and connect the lost moment. Women never tire of hearing about or telling their birth stories, whether it is five, 25 or 105 times.

Ms Bevan: We are also concerned about the single mothers, those of them who are young and scared. Most of the single mothers that you hear about are younger and alone. Having a normal birth alone, without a partner, is frightening enough. To be in a high-risk situation in that cycle of intervention, with machines and IVs, would be absolutely terrifying. If that woman can access midwifery care in a supportive role, with her physician as a primary care giver, then she can still have that familiar, trusted face to provide continuity and to make the birth experience and that entry into parenthood as positive as possible.

Ms Haffie: My first son was born by caesarean section. The diagnosis was "failure to progress." My family physician was discussing her living-room drapes as the obstetrician was slicing me open, discussing home renovations when I felt the anaesthetic was freezing my lungs and I really felt like I was going to die.

Before the conception of our second son, my husband and I decided we would hire a midwife. We wanted to build a trusting relationship with one of those guardians of the normal birth so that if my second pregnancy had ended in a caesarean section, we would have been assured of its necessity. And a midwife at the same time would have made sure that caesarean birth was a birth experience and not an operation happening to me.


Ms Bevan: When I had my son -- we are talking about birth experiences here -- I had a wonderful pregnancy. I loved being pregnant. But the labour was another story. I was put to bed. I was not allowed to eat. I was anaesthetized, monitored, and I had a C-section too. I saw lots of faces, but did not know very many of them. I had looked high and low for a doctor I trusted and whom I felt comfortable with and I saw her for a maximum of four hours out of 38 at the most.

I was not told that when I had epidural anaesthesia I would have these horrible, tremendous shivers. I was not told that epidurals slow contractions and thus labour and lead to more complication. Although I can never prove it, I feel in my heart that many of these interventions were unnecessary. By providing continuity of care and informed choice, I feel that a midwife could have empowered me to avoid these interventions. If I had had access to midwifery care, maybe some of this could have been prevented.

Thus, we would like to ask the following questions about the act:

Given that the midwifery scope of practice as defined in the act refers to normalcy, a scope of practice under normal conditions, will women who are assessed as high risks still be able to access midwives in a supportive role? Will this be legal? Will it be paid for? And will the decision to retain the services of a midwife, after transfer of care to a physician has occurred, remain with the client? Will that woman still be able to say, "I want my midwife with me even though I am seeing a physician"?

Ms Haffie: We would also like to ask the standing committee for clarification regarding consumer representation on the governing council of the College of Midwives of Ontario. On April 2 of this year, Minister of Health Evelyn Gigantes announced that public representation on the governing councils of health professions would be increased from one quarter or less to just under half, and we have appendixed that to the presentation as well. Bill 56, however, as far as I can figure out, provides for a maximum consumer representation of only 38%, and I wonder if maybe you could address that in the question period.

Ms Bevan: In summary, we are pleased to support Bills 43 and 56. We feel that the Regulated Health Professions Act will empower the health care consumer, will put the consumer back in the decision-making position. Similarly, the Midwifery Act will allow all women who wish to access midwifery care to do so, regardless of their financial status. It will put the woman back at the centre of childbirth, instead of the health care provider.

We feel the implementation of legislated midwifery in Ontario will allow better consumer involvement in health care, will result in healthier births and will save money on health care and hospital services. We proudly support Bill 56 but we reiterate our concerns that the definition of normal pregnancy and labour may cause some problems and that it is necessary for all women, regardless of risk assessment, to be able to access midwifery care.

Ms Haffie: Midwifery consumers are proud and excited to be so close to realizing our dream. We have been working hard for over eight years towards the recognition and legalization of midwifery. It is very close and we are very excited. This legislation did not just happen; you listened to us. And we thank you for listening to us today.

The Chair: Thank you very much for a very thoughtful and excellent presentation. I will ask the parliamentary assistant to respond first.

Mr Wessenger: If I might respond to the whole question of the governing council, an amendment will be tendered at the clause-by-clause stage of the discussion of the bill. Right now, I understand the whole question of numbers is a matter of discussion with your council. Once that is agreed to, I assume that it in fact would be the figure that is agreed to and that will be put in the bill. So it is being worked out, as I understand.

Ms Haffie: I am sorry. This is the interim regulatory council which will be working out the numbers?

Mr Burrows: The numbers for all of the governing bodies, in light of that policy statement of the minister, are being discussed with whoever the authority is. In the case of an existing profession, it is the existing governing body. In the case of those to be regulated, it is the group which is seen as being the voice of the profession. That consultation is going on. We have received input. It has been digested. In some cases there is acceptance, in some cases there is a request for clarification, and so forth.

When that process is complete we will be recommending to the minister specific composition numbers and, if approved, they would form the basis of amendments at clause-by-clause.

The Chair: There were other questions that were asked regarding midwives in complementary care, as well as whether this would be covered. Do you want to answer that at this time?

Mr Wessenger: I will comment on it. First of all, with respect to "in a supportive role," that of course naturally would be allowed with the physician's agreement. So that would be legal in those circumstances, but it would have to be worked out with the individual physician.

With respect to the other matters, they have not yet been resolved.

Mr Martin: I rather enjoyed your introduction as you spoke about sitting around the kitchen table and discussing this. You are in rather an enviable position, I think, as a group, talking among yourselves about how this particular service might be delivered and then coming up with some of the rules around, I suppose, what credentials midwives may have. It is certainly an issue that has been raised at this level, and my question would be around that.

It seems to me that probably most of the health professions started somewhere back in history at that same place, where consumers who had a concern gathered and decided how they might react to it. In many professions, we have in my opinion become somewhat too concerned with credentials and less concerned with the issue of compassion and caring.

In your discussions around credentials, how have you aligned the need for, I guess, proficiency with the need for making sure that those who do enter the profession are the caring, compassionate folks, who may not be able to get into university or perhaps go beyond the three-year general arts or science into a more specialized area, and who would probably make terrific midwives? That for me reflects back to sometimes wonderful people in communities who would make great social workers and who never become social workers because they cannot get their MA.

Ms Bevan: There is a curriculum development council on midwifery that has come up with a document basically talking about what you were talking about. We did not append this to our submission, but I am sure it is available.

The MTFO supports the recommendations in the CDC report, and as far as I know those talk about entry into midwifery being direct access, so direct entry into midwifery, and it being a very individual situation. Again, I am not well versed on this; I have read the CDC report but I am not an expert on it. But the impression I get is that when people want to become midwives, they are looked at on an individual basis for their criteria, for their -- what am I trying to say? What is the word I am looking for?

Mr Martin: Suitability?

Ms Bevan: Yes, whether or not they will make good midwives, basically. On a personal basis, I am more concerned about my midwife being competent and being a good midwife than whether she can pass a pharmacology course or not. That is much more important to me, but that is just a personal opinion.

Mr Owens: The question I would like to ask is to legislative counsel through the parliamentary assistant. The two presenters touched on a very good point with respect to what the philosophy of this legislation is all about. I believe it was Michele who talked about the physician suggesting that for her second pregnancy, as she was post-Caesarean, that a natural birth or a midwife would not be the option of choice. It confounds me since VBAC now is coming into the literature as the preferred method of delivery.

What is the ministry doing in terms of going to either the College of Physicians and Surgeons or communicating with the Ministry of Colleges and Universities to ensure that the philosophical change is going to occur at the training level and not hope that it percolates down to the doctors somewhere in the process, as they will be the persons left to assess who would be eligible to have the services of a midwife?


Mr Wessenger: I will refer that to ministry staff.

Mr Burrows: I am not sure I can fully answer the question, because I am not particularly expert in this area, but my understanding is that this type of activity is in fact occurring under the aegis of the interim council. They are looking at the educational program, for example. They are looking at how the scope of practice might possibly be translated into practical terms. One would expect that once the legislation is passed and we have a transitional governing body, with the authority of legislation coming, there would be intense discussions between the newly to-be-regulated professions at the governing body level, the college level. It is not unusual for that to occur.

As an example with nursing, right now what happens is that the two colleges under the Health Disciplines Act, if there is a question about a delegated act, would be expected by the members of that profession to enter into a dialogue to come up with a suitable agreement that both professions could live with. One would expect that sort of respectful dialogue to occur.

Certainly with the declared policy intent of not only the current government but past governments behind this, one would expect there would be a great deal of popular support for that kind of process being a very meaningful and intensive one. Also, I would refer to the statements of the minister and the two former ministers at the time of second reading of this legislation, in which it was clear that the government is fully behind this activity and has the expectation that midwives would become full members of the health services delivery team. I think that is about all I can say, that they would have the full force of government policy intent behind those discussions.


The Chair: I call now the Registered Nurses' Association of Ontario, region 2, London, Huron, Perth, Oxford and Elgin county.

Ms Martin: My name is Anne Martin. I am the president of the Middlesex North chapter of the Registered Nurses' Association of Ontario, more simply known as RNAO. My fellow presenter today is Laurie McKellar. She is the chair of our political action committee. Today we are representing region 2 of the RNAO, which encompasses the Middlesex North, Middlesex South, Oxford, Perth and Huron chapters, or approximately 1,250 nurses. We thank you for this opportunity to address the social development committee on the Regulated Health Professions Act.

RNAO's mandate as a voluntary professional association for registered nurses is to lead the profession of nursing into full partnership in the practice and shaping of health care in Ontario.

RNAO believes that the principles of public protection and provider equality make the RHPA a cornerstone in health legislation in Ontario. This legislation will affect existing and proposed legislation, as well as institutional and community structures. However, it is imperative that the RHPA reflect current nursing practice and provide for the evolution of health services and provider roles.

Given the time restrictions today, we would like to concentrate on just two of our issues. We would refer you to our brief for our additional recommendations. The reason we have chosen these two areas of concern is due to the powerful impact these legislative barriers would have upon the present care we provide our patients.

First of all, I would like to provide you with a general view as to nursing's scope of practice:

"The practice of nursing is the assessment of the health status of the client, resulting in a nursing diagnosis, plan of care, implementation of the plan and evaluation of the outcome. The care may be implemented through means of support, health promotion, prevention of illness, advocacy, teaching or counselling, palliation, rehabilitation and therapeutic intervention in order to attain or maintain optimal functioning."

Please keep this description of nursing practice in mind as we discuss the following urgent issues.

The first issue: "Communicating to the individual or his or her personal representative a conclusion identifying a disease, disorder or dysfunction."

In the act it is written that this is to be a controlled function. This must include a nursing diagnosis. A nursing diagnosis must not be confused with a medical diagnosis. A medical diagnosis is arrived at after analysis of a patient's clinical data and may require surgery, a prescription drug or other modes of treatment that are legally defined. This differs from a nursing diagnosis, which is an actual or potential problem-centred description of an unmet human need that requires nursing intervention. This process requires collecting, analysing, recognition of a pattern and validating clinical data, along with an individualized patient assessment.

Nursing diagnoses were designed to ensure high-quality patient care through the continuous application of theory and research-guided practice, the documentation and communication of effective or ineffective interventions and continuity of care by means of the development of an individualized plan for patient care.

For example, after a thorough patient assessment, collection of data, etc, a registered nurse has developed the following care plan for a patient who is assessed to be experiencing pain after surgery. Pain relief is a paramount concern in patient care, as pain can prolong recovery and bring on complications such as pneumonia and stroke.

The diagnosis: altered comfort level related to inadequate pain relief.

Our goal for this patient would be to obtain pain relief. The nursing interventions might include: to administer analgesic, or a pain killer, as appropriate; monitor and document pain quality, intensity and duration; collaborate with the physician to adjust analgesia dose, if appropriate. Expected outcomes for the patient might be that the patient would verbalize comfort and pain relief, report the ability to sleep, and we might note an increased level of activity.

Another goal for this patient might be to employ stress reduction or diversional relaxation to augment the analgesic effect. Nursing interventions might include: providing information about relaxation, guided imagery or diversional activities; teaching and monitoring the selected strategies; determining with the patient what activities precipitate or alleviate pain. Our expected outcomes for the patient might be that he would use music, TV and radio for diversion, use progressive muscle relaxation and collaborate with the nurse to evaluate the selected strategies.

From this example, we can see how a nursing diagnosis, with resultant interventions and plans for care, differs from a medical diagnosis and follow-up medical care. Obviously, this nursing plan for care is within the scope of nursing practice, independent of medical practice, and ensures the delivery of high-quality patient care.

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

Our next issue can be located on page 3, under the Nursing Act.

In the Nursing Act, some authorized tasks for nursing are "on the order of a qualified person." This should be deleted from the act, as it threatens to interfere with prompt care-giving if the nurse is required to obtain an order to execute a task that is presently done independently and is fully within the registered nurse's realm of knowledge and expertise. These limitations are indeed a step backwards for health care at a time when the new vision on health strategy intends to remove barriers that prevent the more flexible use of health care personnel.

These restrictions hinder the nurse's ability to alleviate the discomfort a patient is experiencing when, for example, he is unable to clear his airways as a result of a lung infection and requires suctioning. Presently, it is within the nurse's domain to initiate suctioning if it is assessed to be necessary. However, if the nurse is required to get the order of a doctor, he or she would have to obtain the services of a physician. The physician in turn would be required to make his or her own assessment of the patient's condition and decide whether suctioning would be in order. Meanwhile, the patient continues to choke and suffocate on his own secretions. This truly is time that is wasted and puts the patient in a potentially dangerous situation. Bear in mind also the additional barriers to timely patient care for the nurse who cannot readily access a physician, like the nurse in a small community hospital or an outpost nursing station. As you can see, with these constraints it is indisputable that when the nurse's hands are tied, superior patient care is jeopardized.

The nursing profession has historically been fully accountable to the college and ultimately the public in conducting these tasks in the past. To restrict these acts is a departure from the vision reported in the Premier's Council report on health human resources, where it was emphasized that there is a pressing need for engineered change in the system and for better utilization of current human resources.

The Regulated Health Professions Act is important legislation which enshrines public protection and provider accountability. However, we cannot support this legislation as it stands. We believe it is a step backwards and as a result is a threat to the superior quality of patient care that the people of Ontario presently enjoy.

Once again, we thank you for the opportunity to present our concerns to you today and we would be pleased to discuss any of these issues now or in the future.


Mr Hope: I am going to touch on a topic that you did not bring out, managing and conducting of delivering of a baby. I wish I could ask the midwifery this. We seem to determine whether it is the physician, the widwives or the nurses who are involved. I have to ask this question, because I was involved in the delivery of both of my children. Where do I play that role? As a father and as an activist who believes in being a part of birth, where is my role? It seems that the partner is being left out, and I would like to be a part of that. I enjoyed the two that I did have, but I have to ask that question. Is it a battle of the professions, or are we forgetting about the spousal aspect of things too?

Ms Martin: I think the partner in delivery can be an assistant in some senses to the nurse in providing comfort measures and pain relief for the mother, so I think you do have a valuable part in the delivery process.

Ms Haeck: I appreciate your remarks. This morning I had a chance to discuss standing orders with some nurses in the hallway after we had had some long discussions about this with another presenter. You are basically concurring with their remarks, that you feel that standing orders or some of the other protocols that may be in place do not provide you with the kind of security in your normal job functions under this act or even as it presently exists. Am I correct in saying that?

Ms Martin: That is correct.

Ms Haeck: Those nurses, who are in fact still in the audience, indicated that what is currently happening is something called triage. Do you feel that the act in any way will give you protection in the process of performing triage?

Ms McKellar: I am not really prepared to answer that question.

Ms Haeck: If the hospital sets up a protocol which says that you, as a nurse, are in fact entitled to perform triage, will Bill 43, as well as Bill 57, provide you with the protection to deal with not just "on the order of a qualified person," but the whole process of performing patient care? Do you feel that there are protections in that protocol?

Ms McKellar: To perform triage?

Ms Haeck: Yes, by performing triage.

Ms McKellar: I honestly cannot answer that question at this point. If you like, I could look into it and get back to you on that one.

Ms Haeck: I would appreciate your remarks, because if that is the way practice is going, then possibly the language of either act should be reflecting what is current practice.

Ms McKellar: Okay.

Mr J. Wilson: It certainly is an excellent brief, especially the couple of real-life examples you gave us about what nurses do in their day-to-day functions.

I gather the review committee must have deemed as emergency cases such as suctioning, in the case of the ingested fluids that you mention in the example, and put a provision in the act to allow for emergency cases. I just want to give you the opportunity to clarify that. I find that rather demeaning to nurses, that it would have to be an emergency before you are allowed to perform your duties. Does that at all reflect what you do now? I have to admit, a number of the examples that have been given in this committee seem to be emergency situations. Can you just elaborate on that?

Ms Martin: In this case, where we have given you the example of suctioning, where I work, in an intensive care unit, it is an hourly thing with some patients, and to have to go get an order each hour to suction a patient is a little ridiculous. I understand that for any patient who is intubated with a breathing tube, etc, or experiencing respiratory difficulties, we could have a standing order to suction, but why would we need it when up till now we have been doing it independently and we are fully accountable for our actions? So it just seems to be a step backwards.

Ms McKellar: Many times, when someone initially needs suctioning, it might not be in an emergency situation, but if you leave it for too long it could very definitely become an emergency situation, and you have further repercussions on other parts of the person's body.

Mr J. Wilson: I expect the legal repercussions would be you would have to prove that it was an emergency situation.

Ms Martin: Possibly.

Mr J. Wilson: The onus of proof, as the act reads, would be on you.

Ms Martin: You mean if we went ahead and suctioned?

Ms McKellar: Without an order.

Ms Martin: Yes.

Ms McKellar: As the act stands now, yes.

Ms Martin: It could be a problem proving to them that we in fact thought it was an emergency situation.


Ms Bandur: My name is Donna Bandur and I am president of the Ontario Association of Speech-Language Pathologists and Audiologists. I am addressing this committee today as a practising speech-language pathologist in London and represent our professional regional chapter, along with Brian Field, a practising audiologist. I will devote the first portion of our presentation to address concerns regarding title restriction, diagnosis and the use of the title "doctor." Brian will close with a discussion relating to the controlled act "prescription of a hearing aid."

Speech-language pathologists and audiologists in our region strongly support the principles of this new legislation. The public is without question entitled to quality care with a mechanism in place to ensure the competence of the service providers. Those suffering from communication problems are particularly vulnerable and perhaps are those most in need of protection to ensure that their rights are exercised and that their needs are thoroughly addressed. They may not be capable of asking the right questions or perhaps of understanding their answers. When I speak of that, I speak of people who may be neurologically impaired, so that their speech musculature is paralyzed or they may have difficulties in comprehending speech due to stroke. It is therefore of paramount importance that appropriate safeguards are in place to protect these disadvantaged persons.

To this end, I raise some concerns regarding the legislation as it is currently proposed. First, it is recommended that Bill 44, subsections 15(1) and (2), outlining the use of the title "speech-language pathologist," be expanded to include the title "speech therapist." Because the general public equates these two terms, there is risk that persons seeking speech-language intervention would not necessarily differentiate between practitioners and their qualifications, thereby failing to make informed choices. We also urge that the phrase "in the course of providing health care" be removed, as it further limits the protection of the public. Many speech-language pathologists and audiologists are employed outside of traditional health care settings. They may work in private practice, education or industry. Title protection is just as, if not more, essential in settings where medical models of service delivery are not utilized. As well, the importance of a stronger holding-out clause is urged. Use of terms such as "audiological services" and "speech-language pathology services" would quite naturally lead one to assume that these services are provided by qualified audiologists and speech language pathologists.


With Bill 43, subsection 26(2), speech-language pathologists and audiologists would be prevented from continuing to provide a most essential component of their service continuum. Following often very lengthy detailed assessment procedures, individuals expect that a thorough interpretation of these results will ensue. It is our strong conviction that those professionals with the most comprehensive knowledge of these tests and their interpretation be the ones to convey the appropriate information. Persons who have limited communication skills require careful, sometimes simplified explanations in order to understand and begin to adjust to the symptoms of their conditions. Speech-language pathologists and audiologists receive specialized training in communicating with those who cannot express themselves through speaking or writing, and may have very limited understanding of spoken or written information.

In my own clinical practice, I see victims of stroke daily who are devastated and frightened by their loss of communication. They, and their families, have specific and ongoing questions regarding their deficits, and are relieved when I can provide easily understood explanations in a timely manner. This may necessitate my speaking slowly with simplified grammar and in shorter sentences. It may require the use of drawings and gestures to supplement what I say. Whatever approaches I do use, however, depend on the specific communication problems of that particular person. To refer their questions to someone with less information, and less skill in conveying that information, would compromise the quality of care by adding more stress and confusion to those already experiencing considerable loss.

Finally, I would like to offer my concluding comments on Bill 43, section 30, restricting the use of title "doctor" to five professional groups. I have many colleagues who have spent years in advanced training to earn their doctoral degrees. To disregard their PhDs, while at the same time recognizing those of others, would be a failure to acknowledge their professional contributions and would result in an atmosphere of inequity. I ask that the committee reconsider this exclusion in order that audiologists and speech-language pathologists holding doctoral degrees are able to use the title "doctor." I would now like to offer Brian the opportunity to conclude our presentation.

Mr Field: This committee has listened to a number of presentations and read many briefs concerning the prescription of personal hearing aids. No doubt there is much more to come. To date, three major concerns have been raised about the proposed legislation. It has been suggested that changes in the legislation will: (1), reduce public access to hearing aid services, specifically in non-metropolitan areas; (2), will substantially increase the overall cost of Ontario's health care system; (3), will result in a gold-plated system, because lesser-trained individuals could prescribe hearing aids quite competently with no risk. I will limit my presentation to these three points.

1. Public access to hearing aid services: Concerns have been raised that limiting prescription of a hearing aid to audiology and medicine, and separating authorizing and dispensing, is causing, through the limitations now in effect through the assistive devices program, and will continue to cause, major access problems for people who need help. A previous Association of Hearing Instrument Practitioners presentation outlined a drastic picture suggesting extensive waiting lists in the province for audiological services and poor access to the services in non-metropolitan areas, while implying that its members provide the majority of services in these areas. The submission by the Ontario Association of Speech-Language Pathologists and Audiologists, OSLA, to this committee on August 12, 1991 in Toronto contains the report access to Audiology Services 1990, appendix 9.4 in the OSLA brief. The data was provided by the assistive devices program, the Workers' Compensation Board, the Department of Veterans Affairs, as well as our own research.

To summarize, this data shows: 71% of hearing aid authorizations in Ontario are currently provided by audiologists; 65% of all ADP hearing aid authorizations are provided by audiologists; audiologists authorized the majority of claims in both metropolitan, 62%, and non-metropolitan areas, 72%; audiologists provide the majority of hearing aid authorizations in traditionally underserviced areas such as the northern, 72%, and eastern, 64%, regions; the average waiting list in Ontario for a hearing aid evaluation is 3.1 weeks; the majority of claims authorized by non-audiologists, 73%, occur in metropolitan areas.

It is clear that the majority of hearing aid authorization services currently provided in the province are done by audiologists. It is apparent that, despite AHIP's statements to the contrary, the major contribution to access made by non-audiologist authorizers is occurring in metropolitan areas where access to audiology services has never been considered problematic. AHIP has emphasized an attrition of non-audiologist authorizers and service clinics since the expansion of the ADP program in January of 1989. Despite the number of service clinics which were reported to have stopped operating since January 1989, in all instances, with the exception of one community, services remained available in the community. And that is shown to you in appendix A.

At the time, new ADP regulations were being introduced. Many of the statistics and research now available had not yet come to light. As a result, the grave concerns about access to service were understandable in the late 1980s. To try to eliminate any potential loss of service and to protect livelihoods, ADP, with the agreement of OSLA and AHIP, grandfathered about 180 hearing aid dispensers who authorized and dispensed hearing aids before January 1989. These individuals could continue to provide both services after passing a competency exam. In light of factual information concerning access to both authorizing and dispensing services, the executive director, consumer services division, Ministry of Health, recently made the following statement: "After reviewing the information presented by the associations" -- that is, AHIP and OSLA -- "represented at the November 1990 meeting, the assistive devices program data on hearing aid authorizations and sales, and information collected from other sources such as district health councils and Ministry of Health field offices, we have concluded that there is not currently a significant problem in accessing hearing aid services across Ontario." That letter is in appendix B for you.

2. Cost of audiology services to the health care system: It has been suggested that as a result of this provision, costs to the health care system will increase dramatically, particularly the OHIP billing costs associated with audiology services. This issue requires clarification. OHIP is a payment scheme for physician services in both private practice and in hospitals. Audiology services, under OHIP, both in hospitals and in private practices, are delegated medical acts. As such, 40% of these OHIP billings are paid to physicians for their supervision of other individuals providing billable audiology services: nurses, audiologists, those whom they may employ. The remaining 60% is paid to the physician to cover the cost of equipment, space, and to pay the person who does the testing. Thus, attributing OHIP billing costs specifically and entirely to audiologists is misleading.

The fact is 80%, 200 of the 250 audiologists practicing in Ontario, are salary employees working for public institutions. The average salary of an audiologist is $45,000 per year. The remaining 50 are employed by physicians in private practice settings. Once audiologists are legally regulated in their own college, any need for direct medical supervision falls away. This transfers the responsibility for assessments performed by audiologists from the medical doctor to the audiologist, where it belongs. The stage is then set to eliminate needless OHIP payments. We believe the cost of providing audiology services could be significantly reduced. With respect to future funding, particularly for non-institutional or community based settings, OSLA supports alternative funding methods that would allow for future service developments outside of the traditional fee-for-service format. This step would seem a logical extension of the legislation, and is consistent with the intent of the legislation to "permit the evolution of a more flexible, rational and cost-efficient health care system."


3. Risk of harm: The inclusion of prescription of a personal hearing aid as a licensed act is certainly justified by risk-of-harm criteria. It is essential to realize that the prescription of a correct hearing aid is but one component of the comprehensive program to help patients. Prescription of a personal hearing aid is one outcome of the proceeding assessment and diagnosis, and must be undertaken with appropriate counselling and guidance as well as the provision for other rehabilitative strategies, including auditory training, speech reading, teaching social strategies for coping with hearing loss, or the selection of supplementary or alternative listening devices. Prescription of a personal hearing aid is not a discrete technical act but rather a process which relies on significant technical expertise, combining the results of assessment and diagnosis with an individual's social, emotional, and physical needs and/or limitations. By virtue of training, an audiologist is in a position to accurately determine needs on an individual basis, and to produce an appropriate prescription, if necessary. Audiologists are not dictators who say, "This is the hearing aid you must have." We try to take into account the patient's needs in a holistic approach, listen to what is important to them, and then try to direct them to the device that is going to properly fill that need.

As indicated in previous submissions, audiologists are the only group of health care professionals who receive specific training in both the assessment and rehabilitation of hearing disorders and dysfunctions. This is of utmost importance, particularly in determining the need for further medical follow-up; for example, in case of unilateral, sudden or conductive hearing loss. And there I am talking about misdiagnosis of problems.

Summary: The licensed act of prescription has been debated, using arguments about the presence of physical or emotional risk of harm, resulting access difficulties and resulting cost impacts. The existing legislation only ensures that a hearing-impaired individual considering use of a hearing aid is assessed by either a physician or an audiologist in the province of Ontario. This provision in the legislation offers consumer protection and lays the groundwork for a more rational, cost-effective hearing health care system without compromising access to service.

Mr J. Wilson: Just to play devil's advocate for a minute, a number of members of the provincial Parliament have received letters from constituents, normally older constituents, who indicate they are quite happy with the service they are now receiving from hearing-aid dispensers. They tell us they do not want us to force them to have to go to an audiologist or an MD prior to receiving hearing-aid services. For the record, what do we say to them?

Mr Field: What is our concern? The concern is that a serious medical problem could be missed. Such items as an acoustic neuroma, or cholesteatoma, are hidden items in a simple assessment that would not be noticed by someone doing an assessment strictly for the purpose of fitting a hearing aid. If those items go undiagnosed it could result in death. Both of those are life-threatening disorders. The earlier they are caught the better. Audiology is one of the first-line defences against those two particular pathologies.

Mr J. Wilson: But have we had documented cases of harm for people that have been misdiagnosed?

Mr Field: Been misdiagnosed? There is lots of it in the literature.

Mr Beer: One of the other issues that has arisen from consumers in the survey -- we have had a number in the hard-of-hearing community who have indicated the problem if their hearing aid is lost or broken or whatever and they are not in a community that has an audiologist. If they cannot get access to a new hearing aid quickly, it can have a very dramatic impact on their job and their working conditions.

How would you see that sort of situation evolving? Let us supposed I lived in a community that did not have an audiologist. I had been assessed, fitted. How would I be able to get that quickly under the proposed legislation?

Mr Field: It is pretty much standard practice currently that anybody who dispenses hearing aids has a set of consignment aids or loaner hearing aids that are available to individuals if their hearing aid suddenly breaks. For example, if your hearing aid just broke down, it usually takes about two weeks for a hearing aid to be sent into the manufacturer, repaired and returned. That is average. The same problem exists over those two weeks. How does one handle not being able to hear over that time? Usually loaner hearing aids are available from any dispenser. One possible way to handle it is through a loaner hearing aid, until such time as a new assessment and prescription can be undertaken.

The other thing, of course, is how current does an assessment need to be, to require a new assessment before a prescription is made? The standard practice now, at least in my practice, is that if it has been more than a year I consider that I should reassess their hearing before prescribing a new hearing aid, so if there has been a change in their hearing that can be incorporated in the new hearing aid. If we based that on last year's results, and if they have lost their hearing aid in the intervening time, I may well prescribe an inappropriate hearing aid for them.

Ms Haeck: To follow up on Mr Beer's comments, we have had those consumers out there saying that they have felt that the audiology community, the profession as such, has possibly not been as responsive to their need for a variety of hearing-aid appliances. Any comments?

Mr Field: Do you mean by that other items as well as their hearing aids; other assistive devices that they might wish to use?

Ms Haeck: That there is a range. One gentleman says that he has about eight different appliances that he may or may not use. Other consumers have felt they have been dictated to about their type of hearing aid, without really having access to a broader spectrum.

Mr Field: I think on closer examination you would find that audiologists are probably the most well-versed group of professionals about assistive listening devices. That is part of our training. We are not trained to know only about hearing aids.

One of the important aspects about prescribing a hearing aid is to find out what other areas of difficulty an individual has, what hearing aid might be compatible with other assistive listening devices they might require, such as an FM system or external microphones or other things? If, in fact, a wrong hearing aid is prescribed that is not compatible with some future system that they might require, that has been a poorly prescribed hearing aid. The way I have been trained is to look at the whole person's needs. If I can see any reason why they might require such an assistive device, I make sure they understand that for that reason we may need to go to this type of hearing aid so it will be compatible with that particular device. That is part of the assessment.

Ms Haeck: Now, this person was specifically concerned around a lifestyle issue. Someone who needed an FM system was given a prescription for something in the ear and, in fact, it did not work. That was only option he was given by the audiologist as opposed to something else.

Mr Field: I cannot answer what the audiologist might have seen in that case. I do not know. Certainly that is not normal.

The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee today. I know you realize that if there is additional information, you can submit it to the committee at any time in the course of our hearings.

Mr Field: Thank you very much.

The Chair: The committee officially stands adjourned until 9 am -- please note 9 am -- Monday morning in Ottawa.

I have some housekeeping for committee members. Cabs to the airport will be outside at 4:45 sharp. They are grey. There will be three members to a cab and the clerk requires your air stubs from your tickets, which she will collect at the airport. Any additional information you can ask for yourself.

The committee adjourned at 1638.