Tuesday 27 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 Occupational Therapists

Ontario College of Occupational Therapists

Canadian Association of Occupational Therapists

Respiratory Therapy Society of Ontario

Mary McLelland

Ontario Teachers' Federation

Ontario Association of Registered Nursing Assistants

Carol Kushner

Speech and Stroke Centre

Clarendon Foundation

Canadian Hearing Society

Ontario Head Injury Association

Ontario Association of Dispensing Opticians

Board of Directors of Chiropractic


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)


Jackson, Cameron (Burlington South PC) for Mrs Witmer

Klopp, Paul (Huron NDP) for Mr Silipo

Sola, John (Mississauga East L) for Mrs McLeod

Clerk: Mellor, Lynn

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

The committee met at 1001 in committee room 2.


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

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


The Chair: Good morning. I would like to welcome everyone and call first the Ontario Society of Occupational Therapists.

Mrs Cameron: My name is Debbie Cameron and I am the president of the Ontario Society of Occupational Therapists. With me is Dr Helene Polatajko, past president of the Ontario society, and Christie Brenchley, our executive director.

I would like to begin today by expressing our appreciation for the opportunity to appear before you. I hope that by the end of this presentation you will have gained a better understanding of occupational therapy, our society and its position on the proposed Regulated Health Professions Act.

The Ontario Society of Occupational Therapists, or OSOT, as I will refer to it, is a professional association of occupational therapists eligible to practise in the province of Ontario. Incorporated under letters patent in 1921, OSOT was the first professional organization of occupational therapists in Canada. Today the society works on behalf of Ontario's 2,300 therapists to address and promote issues relating to education, government affairs, professional issues and public relations.

Occupational therapy as a profession developed in Canada after the First World War. Working with veterans, therapists demonstrated the positive and important contributions that the application of purposeful and meaningful activity made in the rehabilitation of individuals with physical and emotional dysfunction.

Occupational therapy addresses problems in functional or adaptive behaviour in persons whose occupational performance -- self-care, productivity and leisure skills -- is impaired or likely to be impaired by illness or injury, emotional disorder, developmental disorder, social disadvantage or the aging process. The purpose of intervention is to prevent disability and to promote, maintain or restore occupational performance, health and wellbeing.

Because problems in functional or adaptive behaviour can occur with anyone, OTs work with a diversity of client populations. This brings the therapists in contact with a broad cross-section of Ontario's population bridging all age groups, social sectors and cultural diversities. The occupational therapist may be involved in providing direct treatment, mediator training, consultation or research.

Ontario's OTs work in a wide variety of employment settings: hospitals, schools, nursing homes, home health agencies, developmental centres, rehabilitation centres, community mental health facilities, sheltered workshops, private practice and the workplace.

With a philosophical commitment to interdisciplinary teamwork, most OTs work as integral members of treatment teams with physicians, nurses, physiotherapists, community workers, etc. Trends towards community-based and accessible health services have placed increasing demands on occupational therapists whose expertise lies in facilitating the personal independence and functional performance required for successful community living.

In summary, if you, a family member or a friend knows a child with a physical disability, a teenager with a head injury or perhaps a spinal cord injury, a young adult who is mentally ill, a middle-aged acquaintance with multiple sclerosis or an older person with Alzheimer's, then likely an occupational therapist has been involved at some point in their rehabilitation process.

The Ontario Society of Occupational Therapists registers its clear support of the Regulated Health Professions Act. Believe it or not, we have been working on legislation for longer than this government has. For nearly 25 years, occupational therapists in Ontario have sought legislated regulation in an effort to ensure the quality of OT services provided to Ontario residents. We believed so strongly in this concept of regulation that we instituted a voluntary regulatory body, the Ontario College of Occupational Therapists, in 1984.

RHPA will enhance the public protection while providing a framework for a more equitable system which respects the autonomy of individual professions. The quality assurance requirements are innovative and will prove challenging and exciting in their implementation.

Clearly, we are supportive of the RHPA. Of course, we would not be here today if we did not feel that some minor modifications needed to be made. Our purpose here today is to point out our concerns.

With respect to Bill 43, the omnibus act, we have two concerns. Our most serious concern is with the controlled act, paragraph 26(2)1 of the RHPA. This one I am sure you are all very familiar with. It reads, in part, "Communicating to the individual or his or her personal representative a conclusion identifying a disease, disorder or dysfunction."

As occupational therapists, we would concur that the identification of disease is an act which we are not qualified to perform. However, the identification and communication of disorders and dysfunctions is something that OTs perform on a regular basis. In fact, our scope-of-practice statement outlines our obligation to assess function and therefore to identify dysfunction.

We are very concerned that this controlled act will limit current occupational therapy practice. We routinely formulate and communicate conclusions about the causes of symptoms within our scope of practice.

For example, when a client suffers an injury to his spinal cord, perhaps as the result of a diving accident, the physician would make a diagnosis identifying the level in the spinal cord where the injury occurred and the extent of damage. Following this, the occupational therapist would be involved in assessing what the client could still do for himself on a functional level. Due to the amount of swelling around the injury or the time elapsed since the accident, the client's diagnostic level and his functional level might differ. However, to the client and his family, accurate assessment of his remaining skills would be vital. We feel that it is equally vital that clients are able to obtain the results of these assessments from the professional who carried them out. As the act is currently written, the results of this assessment could not be shared directly with the client or his family. This "communicating" would have to be undertaken by a physician.

We understand that this act is not intended to limit current practice, but wording such as "communicating," "disorder" and "dysfunction" are sufficiently vague as to arouse serious concerns among therapists. The controlled act paragraph 26(2)1 as it is currently written could interfere with professionals working as a team by placing those professions allotted this controlled act in the role of gatekeeper of information to clients and families. The economic implications of this to the public purse must also be considered.


Our proposed amendment to solve this problem would be to add a subsection to section 26 which would state that people regulated under the provisions of this act will not be deemed to be in contravention of paragraph 26(2)1 when performing assessments that are within the scope of their practice, including the formulation of assessment conclusions and the communication of such to clients.

Our second concern with Bill 43 is with subsection 30(1), which restricts use of the title "doctor." We understand the intention of this section is to reduce public confusion. However, we feel that this title restriction has several other implications that should be considered.

People are entitled to know the qualifications of the therapist who is treating them and should be able to easily identify and seek out a therapist with higher educational qualifications if that is their desire. The OSOT feels that individuals who have earned their PhD have the right to use the title "doctor." To restrict the use of this title goes against standard practice in other provinces and countries.

The fact that RHPA has legislated that certain health care professionals can use the title "doctor" and not others is discriminatory, inconsistent and lacks justification. The title should apply to all those who have earned it, regardless of discipline. Given the current lack of researchers and educators, the health care system should be doing all that it can to encourage individuals to obtain higher education. These individuals are the ones with the skills to ensure through research that the service provided to the public is of the highest possible quality.

Our recommendation would be to allow the use of the title "doctor" only with the use of the professional designation. In other words, an occupational therapist with a PhD would be known as a doctor of occupational therapy.

With respect to the Occupational Therapy Act, or Bill 58, we also have two concerns. Subsection 14(1) of the Occupational Therapy Act, entitled "Restricted Titles," concerns us. The subsection currently reads, "No person other than a member shall use the title `occupational therapist,' a variation or abbreviation or an equivalent in another language in the course of providing or offering to provide, in Ontario, health care to individuals."

We are uncomfortable with the phrase that limits title protection to the area of health care. In our profession particularly, many members work in areas that might be considered to be outside the health care field. For example, therapists work in school boards, industrial settings and insurance companies. In these settings the title "occupational therapist" would not be protected. Therefore, a member of the public may be misled about the qualifications of an individual practising outside health care. Only when dealing with an occupational therapist in the field of health care could a client be assured of obtaining service from a regulated professional.

We would suggest that simply dropping the last phrase, "in the course of providing or offering to provide, in Ontario, health care to individuals," would solve the problem and offer the public the maximum protection possible.

Our second concern with Bill 58 is in subsection 14(2), which deals with representation of qualifications. Currently this section states, "No person other than a member shall hold himself or herself out as a person who is qualified to practise in Ontario as an occupational therapist or in a specialty of occupational therapy."

The wording in this subsection is not strong enough and places no limitation on unqualified individuals who wish to mislead the public with the use of various descriptors or descriptive phrases. For example, an unqualified person could be claiming to be providing occupational services within a hospital or community clinic. Clients could be misled by the use of such a descriptor into believing they were receiving service from an occupational therapist.

The Ontario Society of Occupational Therapists feels that the public would be better served by a stronger clause which would add to the above section the phrase, "or use any name, title or description implying or calculated to lead people to infer that the person is qualified or recognized by law as a member."

In conclusion, the Ontario Society of Occupational Therapists is very supportive of the Regulated Health Professions Act. However, we feel that the legislation could be strengthened by introducing the minor amendments outlined above. As is clear to us from discussions with many other groups and must be clear to you from previous presentations you have already heard, we are not alone in these concerns.

We appreciate this opportunity to present our views and look forward to continuing to work with all concerned individuals in the future. We welcome the opportunity to answer questions at this time.

The Chair: Thank you for a very thoughtful presentation.

Mr Owens: When a patient comes to see you, he presumably comes to you with a chart, and with a diagnosis listed on the chart.

Mrs Cameron: Not necessarily. It depends on the setting in which you are working.

Mr Owens: Right. If you are working in a hospital setting, for instance.

Mrs Cameron: Likely there would be a medical chart, yes, with the diagnosis listed.

Mr Owens: I guess I am struggling with what type of diagnosing you would in fact be doing. When you talk about the oedema on a patient's hand, is that not just a symptom of an existing diagnosis where you would simply be performing an assessment rather than diagnosing why the oedema is there?

Mrs Cameron: Yes. That is the problem that we struggled with in trying to address this whole question. I guess in looking at it, though, we feel that when it is expanded to say "disorder and dysfunction," although we would not diagnose with a medical diagnosis, we often might label a dysfunction. It is not always clear to us in all cases that a dysfunction could be directly attributable to a diagnosis that has already been made by a doctor.

For example, if you were looking at a learning disabled population, where they may be having troubles in school, you may be called in to assess a child. He may not have been given a medical diagnosis, so you may come up with a label of a type of dysfunction without its having been identified clearly with a medical diagnosis. This is the area where we have trouble with this phrasing. In looking at it and in talking with the ministry people, their intention is not to limit that kind of thing that we do, but we just are not comfortable that the language at this point is clear enough to allow us to continue to do what we normally do.

Mr Beer: Thank you for your presentation. In the same area, around the communication, if the word "dysfunction" were removed from that, how far would that go in making you feel warmer and more comfortable?

Mrs Cameron: That was certainly one of the possible options that we looked at suggesting as we went through it. I think part of our discomfort was that none of those terms are presently defined in the legislation, so we were unsure of the intent in putting "dysfunction" in there and wondered if there were some areas of practice, psychiatry, etc, where there may be a differing definition to the one that we might use.

Mr Beer: I will ask a question through the parliamentary assistant then. In the example on page 6, at the bottom of the page, where it says, "For example, when a client suffers an injury to his spinal cord," and then the physician makes a diagnosis -- in terms of what was described and what follows, I would have thought that would be perfectly legitimate for the occupational therapist to do and that it could not be construed as being in any way communicating a diagnosis or leading to a conclusion, or however the wording goes.

Mr Wessenger: Yes, I would agree with that. In our interpretation we do not see that in any way conveying a diagnosis.

Mrs Cameron: I would like just to add to that. Our reason for using that particular example is that in that area of spinal cord injury, the medical diagnosis might be that the client has suffered an injury at a particular level in the spinal cord. When we would look at it functionally, we might find that due to an incomplete lesion or other factors in the healing process, the client actually functions at a much higher functional level than what might be indicated by a strict medical diagnosis. Therefore, the functional level and the diagnostic level would actually differ. I think that was our reason for using that particular example.

Mr Beer: So the concern is, are you communicating an effective dysfunction of some sort?

Mr J. Wilson: You mentioned in your brief the use of the title "doctor." I am certainly supportive of PhDs being able to use "doctor," but in a case of, for instance, occupational therapy, my understanding is that it is a four-year bachelor of science in OT, that there is no such thing as a doctor in occupational therapy. Is there a doctorate?


Dr Polatajko: There are degree programs in the United States and in South Africa that offer PhDs specifically in occupational therapy. However, most of us who have PhDs have a PhD in a field that adds to what we practise in. For example, I practise in paediatric psychiatry. My PhD is in special education. My PhD deals with learning disabilities, which are the kinds of kids I deal with. Consequently, I feel I am more able to deal with a learning-disabled child as a PhD than I would be as a BScOT.

Mr J. Wilson: I am glad I asked the question. I had no idea the States was offering it.

Dr Polatajko: I think also one thing that needs to be noted is that having PhDs in our profession, and indeed in a lot of the rehab professions, is a fairly new thing, just as accountability is a fairly new thing. As we get more PhDs, it will become a better thing; accountability will become better. When I got my PhD in 1982, I was the fourth in Canada. Right now there are about 25 of us, and right now there are another 20 or 30 who are in the process of obtaining their PhDs. Many of those are in Ontario because Ontario holds most of the therapists in the country.

Ms Haeck: Do you have a breakdown of where the majority of your OTs are working? Are they strictly in a hospital setting or are they in rehabilitative education?

Mrs Brenchley: The Ontario Society of Occupational Therapists represents approximately 1,250 to 2,300 OTs in Ontario. Of our membership, approximately half work in institutional facilities, and with growing demands for community-based and accessible services, we are certainly seeing an increasing number of therapists working in community-based settings, school systems, industry, etc.

The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee this morning. If you have additional information over the course of our deliberations that you think might be helpful or of interest to committee members, I hope you will feel free to communicate with us in writing through our clerk.


The Chair: I would like to call next the Ontario College of Occupational Therapists.

Ms Polgar: Thank you. I am Jan Polgar. I am the chairperson of the council of the Ontario College of Occupational Therapists. With me are Liz Verlaan, the registrar of the college of occupational therapists, and Alice Kusznir, the vice-chairman of the council of the Ontario College of Occupational Therapists.

I would like to direct your attention to page 4 of our document. The Ontario College of Occupational Therapists, or OCOT, welcomes the opportunity to present our views on the Regulated Health Professions Act to the standing committee on social development. While we know that most of our concerns have already been raised, we trust that our words will add strength to those views that have been previously presented.

As Debbie Cameron mentioned, OCOT was established as a bylaw of the Ontario Society of Occupational Therapists in 1984. The purpose of OCOT is twofold: first, it provides a means of regulation of those occupational therapists who choose to become members; and second, it has acted on behalf of OSOT and all 2,300 practising occupational therapists in Ontario on matters that are related to self-regulation of our profession since we have come into being. The college's formation and our development are definitive examples of the commitment of occupational therapists to the protection of the public through a self-regulatory model.

OCOT has formed a number of committees. These include a registration committee and complaints, discipline and appeals committees in order to achieve self-regulation. We have a proportion of lay members on each of our committees. In addition, we have investigated the issues of standards of practice, continuing competence and quality assurance in anticipation of their requirement through the legislation.

OCOT is very enthusiastic about the proposed legislation. We strongly support the purposes of increased public accountability, protection and consumer choice. We find that the requirement for the development of a quality assurance program is very exciting. We feel that quality assurance should be something the professional understands as being important to the development of practice and not as an interference with daily work. We are challenged by the impact which this requirement will have on our research and subsequently the level of care which we provide to our patients.

While we believe that RHPA is important and we definitely support its passage in the Legislature, we have concerns about three sections of the act which we feel will have an adverse effect on public protection and public interest. These sections are paragraph 26(2)1 of Bill 43 and subsections 14(1) and 14(2) of Bill 58, the Occupational Therapy Act. I address first paragraph 26(2)1, Bill 43, about which I know you have heard a lot.

While neither diagnosis nor assessment is defined in the act, we feel that paragraph 26(2)1 implicitly refers to diagnosis. This controlled act does not appear in the Occupational Therapy Act, and it limits those professionals who are able to in part communicate "a conclusion which identifies a disease, disorder or dysfunction as the cause of symptoms."

We believe the public interest will not be served by this section as it is currently written because:

1. Occupational therapists will not be able to communicate the results of their assessment if these results identify the cause of symptoms. So if we identify a dysfunction and relate that dysfunction to the symptoms that the person is having, we will not be able to make that comment.

2. The patient's physician will be required to communicate those assessment results, which will cause delay in the system, potential misunderstanding -- because our idea of the patient is different from a physician's idea of the patient -- and also anxiety on the part of patients as they wait for the results.

3. Patient education that relates to how their symptoms or how their disease or disorder causes their symptoms will be restricted.

4. The college's complaints and disciplines process may be encumbered as patients make complaints against actions which are contrary to the letter of the law but not the intent of the controlled act.

5. Health care costs will rise as patients must see another practitioner in order to hear assessment results.

Daily, occupational therapists perform tasks as part of their practice which may be interpreted as being in contravention of this section. A common example is in the evaluation of perceptual function in a patient who has sustained a cerebral vascular accident. Right-left discrimination is a perceptual dysfunction which is identified by occupational therapists through testing and observation of task performance. Upon identification of this dysfunction, the occupational therapist communicates to the patient how it causes problems relating to dressing or other daily activities. We see that this type of communication will be limited.

Another significant component of our practice is patient education. The occupational therapist may discuss, for example, how the disease of multiple sclerosis causes the symptoms of fatigue. This education is vital to the patient's ability to cope with and compensate for her medical condition. Again, we see that this type of education may be limited by the language of this particular controlled act.

We understand how this controlled act came to be and that it is an attempt, essentially, to operationally define the thought process that is involved in determining a diagnosis. We understand how difficult it is to capture a person's thought process in words. However, we find that the language of this section does not adequately do so and results in the restriction of information that the patient may learn from professionals not granted this controlled act.

We do not want to make a medical diagnosis. However, we do want to communicate the results of our assessments and to provide useful patient education, both activities which we see may be restricted by this section.

We recommend the addition of a subsection to section 26 which essentially would indicate that people would not be in contravention of paragraph 26(2)1 when they are in the process of communicating the results of their assessment to their patients. We believe this amendment would be satisfactory, since it both provides protection to the public from those individuals who are not competent or qualified to make a medical diagnosis and does not limit the responsibility of individuals, regulated health care professionals, to communicate results of their assessments.


In subsection 14(1) of Bill 58, the title "occupational therapy" is restricted in terms of the provision of or offering to provide health care only. We believe that the use of the words "health care" results in inadequate protection to the public. As you have already heard, occupational therapy is a broad type of profession and we do work in situations which may not be considered to be health care or provide activities that may not be considered to be health care.

For example, we do vocational testing in industry, in schools, where we may be assisting an individual to determine a job choice. In this instance the title "occupational therapist" would not be protected, nor would there be regulation of an occupational therapist in that area. So we feel that consumers are not assured that the person providing their services has appropriate qualifications.

We recommend that the section be amended to read, "No person other than a member shall use the title `occupational therapist,' a variation, abbreviation or an equivalent in another language."

Finally, subsection 14(2) of the bill, we believe, does not provide sufficient protection to the public from unqualified individuals who hold themselves out to be occupational therapists. This section does not limit specifically the use of names, descriptions or titles which would indicate that the person is qualified to be a member of the Ontario College of Occupational Therapists. We believe that minimally this section should contain some statements that make it more specific and we recommend the following wording:

"No person other than a member may take or use any name, title, description, variation or abbreviation in another language implying or calculated to lead people to infer that the person is qualified or recognized by law as a member of the College of Occupational Therapists of Ontario."

This rewording is consistent with the recommendation of the Health Professions Legislation Review. We agree with their recommendation and recognize it as one which will provide greater public protection.

In summary, OCOT is firmly behind both the intent and the goals of the proposed legislation. However, we feel that certain sections of it limit the potential of the act to meet its objectives. We commend the government of Ontario for the open consultation which we have been involved in for the last nine years and we anticipate that this consultation will continue as the legislation evolves and grows. We appreciate the opportunity to express our views to this committee and we are confident that the committee will improve on the legislation as drafted to address the problems we have raised.

Mr Beer: When you suggest an addition to paragraph 26(2)1, how do you distinguish between an assessment and a diagnosis when you say that you want to be able to do an assessment? Could you give us an example of what that would mean and how we would relate what you intend to do if we were to put that in with not doing a diagnosis?

Ms Polgar: One of the areas I see could potentially cause a lot of problem is the area I have mentioned, which is looking at perceptual disorders. We do that with a wide variety of clients who have a neurological problem. For certain children, again with learning disabilities, we do a series of standardized tests and we may identify the child as being apraxic or dyspraxic through our assessment.

Mr Beer: Let me just stop you there. When you say you would determine through your assessment that the child was dyspraxic, for example, when you make that determination, what is the difference between saying, "My assessment led me to that conclusion," or, "I made a diagnosis"?

Ms Verlaan: I think if I could just add to that and complement what Debbie Cameron was talking about earlier, we really see it as a continuum, because you have symptoms and then you have disorder and dysfunction and then you have disease. If you see that continuum, there is a cause between the symptoms and the dysfunction, so you get a combination of symptoms and you can analyse a dysfunction. As soon as you use your own intellectual capacity to place some kind of judgement on those symptoms, you have made an assessment.

A step further is the diagnosis, which tends to be more in relation to disease. I know in psychiatry they evaluate disorder and dysfunction and call it by those terms, but generally medical diagnoses are diseases. What we are really saying is that an occupational therapist or any number of these other paraprofessionals place some kind of judgement on symptoms and we want to make sure that those judgements are accurate. Is that reasonable?

Mr Beer: Yes, thank you.

Mr Owens: My question is through the parliamentary assistant to ministry staff. How did the review look at the OTs with respect to their function as it appears as part of a diagnostic team approach? Perhaps not so much in the health care setting, but clearly in the school setting it appears you have more of a free hand, if I am hearing you correctly, with respect to your assessments and your conclusions. How did the review look at these folks in terms of looking at the ideology of a disorder or dysfunction and how these people would function within this legislation?

Mr Wessenger: I will have staff answer that question.

Ms Bohnen: The review thought that occupational therapists are qualified to and employed to assess function and lack of function and that they do not diagnose in the sense that I think the committee has heard elaborated upon, especially yesterday in the Ontario Medical Association presentation. If you take a look at the scope of practice of occupational therapy in the bill, which is identical to what the review recommended, it speaks in terms of the assessment of function and adaptive behaviour. The review thought there was a gulf or a divide between that and the kind of diagnosis that it was necessary to restrict to groups like physicians.

Mr Owens: So was it merely a question of semantics? If you are looking at function, if it is not functional then it is dysfunctional and that is why we have this problem or perceived problem?

Ms Bohnen: I think that this profession's issue is yes, one of their lack of comfort that on the existing language of the controlled act they will not be able to continue what they do even though the review and the government say: "Yes, you will be able to continue what you do. What you do is appropriate. You are qualified to do it." Their diagnosis issue is lack of comfort with what the legislation currently says. I do not mean to demean it by saying it is a semantic issue, but it is.

Mr Cordiano: My question has been answered, but I just wanted to clarify it further. In trying to give some more comfort to this group, we would simply say that what they do is not really a diagnosis of sorts, it is more of an assessment, if you will.

Ms Bohnen: I think that is exactly what the government has said, that what you do is provide an assessment. It is clearly set out in the scope of practice statement. No profession, no government representative, has ever said: "Occupational therapists have a tendency to overstep themselves. We don't want them doing such-and-such." Everybody agrees they are qualified to perform assessments and that is what the legislation permits them to continue to do.


Mr Cordiano: Legally you would be looking at assessments in their realm or their scope of practice rather than crossing the line into what you might consider a diagnosis. It is a legal question basically.

Ms Bohnen: They do not wish to cross the line and to provide medical diagnoses, and the legislation would clearly discourage them from doing that.

The Chair: Thank you for your presentation before the committee today. We appreciate your coming forward and I know that you are aware that you can communicate with the committee in writing at any time during our deliberations.


The Chair: I will call next the Canadian Association of Occupational Therapists.

Mrs McGarry: My name is Jacqueline McGarry and I am the president of the Canadian Association of Occupational Therapists. With me is Anne Strickland, who is our executive director.

I am not going to read through our brief. You have received a brief from us which outlines our concerns about the proposed legislation. I would like very much to thank you for this opportunity. We recognize very well that health care is a provincial matter and we appreciate your willingness to allow us to raise our concerns regarding this proposed legislation.

Our view will of course be from a national perspective. We have close communications with all the occupational therapy associations within all of the provinces. We meet as a group and we are very familiar with both their legislation and their practice. We support the Ontario society and the Ontario college position, and you will see in our brief that our recommendations are very similar to theirs.

One of the things I could alert you to is that we represent more than 5,000 members across the country, all of whom, with the exception of Ontario, are regulated in some way. It is significant because almost 46%, in fact probably this year more than 46%, of our members live and work in Ontario, so that half our membership is not regulated even though every other province is.

I should like to draw your attention to a data sheet at the back of the brief. You were asking about the division of our members and we have last year's data sheet for you there. Unfortunately, it does not break down Ontario per se, but it breaks down our membership throughout the country.

We are in essence supportive of this legislation but, from a national perspective, are concerned with the way in which the proposed legislation might impinge upon our client-centred practice. As a national body, there are many roles that we undertake, one of which is to set standards for the education of occupational therapists. Each of the 12 programs, five of which are in Ontario, subscribe to the standards that we set and are accredited by us.

I should also alert you to the fact that the Canadian Council of Health Facilities Accreditation has used many of our standards as its standards, so that hospital departments accredited by the Canadian association are in a good position to be accredited by the Canadian Council of Health Facilities Accreditation.

Within our programs, we try not to define the method by which they teach the students nor the content of the curriculum. But there is a basic curriculum, and in that the issue of how we practise is taught. The way we teach our students is primarily all within this book, which the Chairman has a copy of. It is more than 10 years of work. It is the guidelines for the client-centred practice of occupational therapy in Canada. It is because all programs and all occupational therapists in Canada work from this that we are concerned with some of the aspects of the proposed legislation.

One of our concerns is with the fact that there is no definition that I can see that clearly says what you mean by diagnosis. For me, diagnosis is usually a medical diagnosis. I would like it clearly spelled out that we are looking at a medical diagnosis. Occupational therapists often contribute to that diagnosis by contributing and collaborating with the doctor in terms of the results of their assessments. What we mean by assessment is very clearly defined and outlined within this book, if that was your question, Mr Beer.

We use many ways of assessing, some of them standardized, some of them personal skills, some of them a review of the family, all sorts of ways that we do assessment. Our concern is not that we want to get caught up in words, but that it really is not clearly defined. We would ask you to review some of the suggestions made by the Ontario college in looking at that.

One of the things we look for is that our members be able to move across the country easily. Our fear is that the proposed legislation will inhibit therapists from other provinces from practising, according to this, within Ontario, primarily because of confusion around the area of assessment and diagnosis.

You will see from your brief that we have quoted to you the province of Alberta's wording, and also the province of Manitoba's. Again, they are not defining that word "diagnosis," as much as we contribute to diagnosis. I can recall an occupational therapist alerting a doctor to the fact that a child had muscular dystrophy -- because her functional assessment demonstrated that. He had gone off looking at mental retardation and delayed development. It was the functional assessment contributed by the occupational therapist that alerted him to the issue of muscular dystrophy. So we contribute to medical diagnosis, but we have no scope of practice that says that we should do that.

Because of the client-centred focus of our practice, where the therapeutic relationship is essential to how we practise, we cannot practise without discussing working with the client. We set our goals with the client. We are looking for motivation from the client to reach these goals. It is that communication area of diagnostic results and assessment results that we are concerned will inhibit our practice.

It is not that we are not trusting. It is that we know people get hooked up with wording. We would ask you to look very carefully at that. Because without the collaboration of the client, without being able to discuss the strengths and weaknesses, without being able to discuss the actual programming with the client, our practice is severely limited. I am sure Mrs Caplan will allow you to review the guidelines we have given, which will outline that very clearly. I would like to turn over to Mrs Strickland.

Mrs Strickland: I will just carry on, if I may, on the other issues we have identified, as have our counterparts. On the restriction of the title "doctor," we are coming at it from a national perspective, thinking in terms of visiting professors who might be coming to teach occupational therapy from either out of country or from another province and of their ability to use the title "doctor." We feel the restriction on the title "doctor" really does not reduce the danger to clients of non-physicians who imply that they may have the qualifications.


I would just like to share with you very briefly a recent example that a member in Ontario brought to our attention. It involved a chiropractor who had signed an assistive devices program form as if he were a medical physician and discussed on the phone with that same member the client's epilepsy, again as if he were a physician. It was only after the fact that the member did find out that the person was indeed a chiropractor rather than a physician, and it was a little disconcerting to her.

CAOT believes that this provision of the act is restrictive and unfair to those who have studied and earned the right to call themselves doctor. In Manitoba, Alberta and Quebec there is absolutely no restriction on the title "doctor." CAOT believes that those who have earned it should be allowed to use it. However, we are concerned with the common practice of using the word "doctor." We suggest that people who have earned the title use it with their professional designation, that is, doctor of occupational therapy, and that they be required to do so. The only exception we would suggest would be the physicians, the medical doctors, because it is common practice in Canada to call a physician doctor without anything else to it.

In terms of restrictive titles, subsection 14(1), as with the other two presentations, we are concerned about the qualifier in the course of providing or offering to provide health care in Ontario. From our statistics and from the statistics in OSOT, you understand that we do practise in other areas outside of the health care field. We really feel very strongly that the public should be protected for occupational therapists who act in all areas of practice.

Mrs McGarry: You will notice on the data sheet that more than 10% I think it is -- and that is growing every year -- practise outside of the institution.

Mrs Strickland: Alberta, Quebec, Nova Scotia and New Brunswick do not limit the practice of occupational therapy to health care at all. In terms of presentations of qualifications, the concern is that the wording is not strong enough to protect the public from those who do not actually state that they are not occupational therapists, but who do imply that they are. This can occur in settings when an activity or a modality is used as diversion, and/or where there is a shortage of professional staff. Both of these situations occur in Ontario. They occur throughout the country. They occur mainly in chronic care institutions and in nursing homes. That is where this tends to happen.

The province of Manitoba has a holding-out clause similar to the one recommended by OSOT and OCOT. Quebec amended its extensive use of title in March 1989 to include the words "leads to the belief that he is an occupational therapist." The Quebec experience is still not strong enough, they feel. The interprofessional council is discussing with the provincial government the possibility of changing the act once again to make this part of its act stronger. We agree with the recommendations of OCOT and OSOT on this particular item.

Mrs McGarry: One of the reasons we are asking that to be made stronger is that we believe it will need to be reopened if we look at the experience of our other provinces who have that in their legislation.

Mrs Strickland: In summary, the CAOT is the national professional organization of 5,000 occupational therapists, 46% of whom work and live in Ontario. Ten per cent of our members work in settings outside of the health care system. We believe that all therapists in Ontario should be regulated under this act. Our concerns are for portability of credentials from one province to another. It must not be easier for an occupational therapist in Canada to go south of the border and practise in the United States than it is to move from one province to another, and we hope that will be maintained. We must keep educated and qualified therapists in Ontario. This is a particular concern right now because there is a shortage of therapists in North America and they tend to be quite mobile and move around.

We have made recommendations or we have supported the recommendations made by OSOT and OCOT. We strongly believe that these changes will result in clarity of the interpretation of the act for the protection of the consumer.

In closing, I would like to thank you for giving us this opportunity to submit this brief. We realize we are the third in the stream of occupational therapists coming forth to address these concerns and I really want to thank you for listening to us and giving us this opportunity. We would be glad to answer any questions.

Mr J. Wilson: Thank you for your presentation. As a national organization, I think it is very useful to hear your perspective. I was particularly curious about your statement that you thought perhaps the proposed wording of the scope of practice statement might inhibit OTs from being able to practise in other provinces and from having the freedom to move within Canada. First, I ask you to expand on those comments. Second, would not the various provincial colleges of OT simply look at academic credentials?

Mrs McGarry: At the present time the entry level to practise in Canada is with an undergraduate degree from an accredited university, with a fieldwork placement of 1,200 hours, and with successful passing of the national COT examination. That becomes your entry to practise and gives you eligibility for membership in the national association. Many of the provinces' regulatory bodies use those criteria. They do not itemize them and they do not put them into their legislation, as membership is essential. But they use the criteria. In that way we are looking at ensuring the consistency of practice across Canada. One of our concerns is that Canadian consumers in Prince Edward Island should have the same access to the same qualified therapists as those in Ontario, BC and Alberta. In that sense, it is a standard, it is a guideline.

Mr J. Wilson: And you feel that our proposed scope of practice is too much of a variation on what other provinces are doing?

Mrs McGarry: I was referring there to the issue of the possible dispute between diagnosis and assessment, what it is, what it means, etc. What the association would not want to happen is for a therapist who had been practising in Alberta or British Columbia to come to Ontario and, because of the legislation, not be able to communicate with a client, not be able to follow through the kind of practice. That is our concern: that we want to maintain the portability across all provinces. That is where our concern comes from -- not that you may have misworded it.

Mr Beer: I want to follow up on this question of health care only in section 14, where there are the three clauses. This would be a question to the parliamentary assistant. The way it is worded in providing health care to individuals, it does not refer to a specific area or to a facility. But is subsection 14(2) intended to catch those who are working as occupational therapists in other places? Or did the review very deliberately want to confine it to what the review determined to be health care so that in fact those working in the workplace or perhaps in schools would not be covered? I would just like to be clearer on that.

Mr Wessenger: Before referring this to counsel for more elaboration, I think it is clear that the concept is health care, not specific health care institutions. But more elaboration can be given on that by counsel. I will ask her to do so.


Ms Bohnen: In the review recommendations which set out the proposed title protection and holding-out provisions, the issue of health care, non-health care, was not addressed at all. If you take a look at what is in Striking a New Balance, you will not see any reference to health care in either the holding-out or the title protection provisions. It was just not there. When legislative counsel came to redraft the review recommendations into the legislation that you see, there appeared to be kind of a vacuum, nothing to anchor the provisions.

Since this was intended to be legislation regulating health professionals, and since all of these professions had, with very few exceptions, agreed to scopes of practice which reflected their activities, whether they be in traditional health care settings or schools, factories and so on, it seemed quite reasonable to anchor the use of the specific title to the provision of health care. But as you correctly point out, the holding-out provision does not refer specifically to "in the course of providing or offering to provide health care."

I suppose when one looked at instances of how the occasions in which a non-occupational therapist might hold himself or herself out as a person qualified to practice, etc, practically speaking, it seems unlikely there would be much percentage in making a misrepresentation of this kind in some sphere of activity entirely unrelated to health care or the kinds of services OTs provide.

The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee today. I think you have heard me tell the others that if there is additional information, you can feel free at any time to communicate with us in writing. We appreciate your appearance this morning.


The Chair: I would like to call next the Respiratory Therapy Society of Ontario.

Miss MacDonald: Thank you, Madam Chairman, and good morning to the group. I am Margaret MacDonald. I am chairman of the legislation committee for the Respiratory Therapy Society of Ontario. With me are Gisella Quintieri, who is the president of the Respiratory Therapy Society of Ontario, and Ian Reid, who is the vice-president.

Historically, the profession of respiratory therapy has been known as inhalation therapy in the 1960s and respiratory technology in the 1970s. In the early years of our profession, many services were primarily technical in nature. With development, the profession has increasingly provided therapeutic and diagnostic services, hence the progression to its current title of respiratory therapy.

The registered respiratory therapist is a graduate of an accredited educational program who has successfully passed the registration examination in respiratory therapy of the Canadian Society of Respiratory Therapists.

The fundamental objective of the Respiratory Therapy Society of Ontario is to promote the best possible care for patients suffering diverse cardiorespiratory disorders. The society is very concerned with how the public is served by the profession. We are also the only body representing registered respiratory therapists as well as other uncredentialled providers of respiratory therapy in Ontario. Hence, we have reviewed Bill 43 and the profession-specific acts, especially Bill 64, An Act respecting the regulation of the Profession of Respiratory Therapy, in great detail. We are therefore requesting amendments and/or additions to the following sections of Bill 64: section 3, scope of practice; section 4, authorized acts; and section 15, restricted titles.

If you would like to refer to page 4 in our brief, it deals with scope of practice. A clearer scope of practice definition will enhance the public's understanding of our role in health care. Our scope statement in Bill 64 suggests a limited scope or role, concluding as it does with the phrase "to maintain or restore ventilation." We deal with patients who have compromised respiratory function and do much in our everyday role, be it diagnostic or clinical, to improve their status, thus avoiding the end stage where they actually require assisted ventilation.

In any description of our role or scope it is impossible to separate the functions of the cardiac and respiratory systems. Therefore, the change we are recommending -- "to maintain, restore and/or promote optimal cardiorespiratory function" -- is much more accurate of our role.

It also expresses our activities in health promotion, which are considerable. An example is the Lungmobile, a public awareness and education program which will be launched in September. The partners in this venture are the Respiratory Therapy Society of Ontario, the Ontario Lung Association, the Ontario Thoracic Society and the Ontario chapter of the College of Family Physicians of Canada.

Respiratory care provided by registered respiratory therapists is ultimately performed under the direction, order or auspices of a physician. Our authorized acts stipulate that they are performed upon an order of a member of the College of Physicians and Surgeons of Ontario. Therefore, the inclusion of the phrase "on the order of a member of the College of Physicians and Surgeons of Ontario" within our scope of practice definition is redundant. It also does not appear in any of the other group's scope statement. Hence, we are recommending its removal.

The next section is authorized acts. Additional specified authorized acts clarify our participation in the execution of procedures carrying significant risk of harm to the public. These additions also avoid the potential for limitation or restriction of our scope of practice.

We did understand at one time that certain acts might be specified in regulations and would not appear as authorized acts. However, when reviewing other professions' acts and also the proposed amendments put forth by the minister on July 31, to avoid limitation, as well as to protect the public, we request these three additional acts. I refer you to page 5 of our brief.

The first authorized act we would like to have included deals with suctioning, "oral, nasal, pharyngeal, and/or tracheal suctioning, with or without an artificial airway in place." This is a routine procedure performed by a registered respiratory therapist that does pose significant potential for risk of harm. In particular, we are concerned when tracheal suctioning is being done if there is an artificial airway, such as a tracheostomy, in place or any suctioning at all in a neonatal practice where certain additional care must be given due to the risk in dealing with these small patients.

The next one is an additional act described as follows, "performing a prescribed procedure below the dermis on the order of a member of the College of Physicians and Surgeons of Ontario." Registered respiratory therapists frequently perform the following procedures: arterial blood gas sampling, venipuncture, intravenous line insertion and the manipulation of pulmonary artery lines to relieve wedging or prevent life-threatening arrhythmias, which is currently a delegated medical act. These procedures pose a significant potential for risk of harm, thus necessitating inclusion of this amendment.

The third additional act we are requesting is that of allergy challenge testing, "allergy challenge testing of a kind in which a positive result of the test is a significant allergic response on the order of a member of the College of Physicians and Surgeons of Ontario." Registered respiratory therapists working in health care facilities where their role includes diagnostic services are being called upon with increasing frequency to perform allergy challenge testing. This allergy challenge testing is included in the controlled acts in Bill 43. Again, potential risk of harm associated with this procedure is great.

The next section we are requesting amendment to is the restricted titles. I refer you to page 8 of our brief. Clarification of who we are, by identifying the primary respiratory care givers as registered respiratory therapists, we feel is paramount to public protection. This issue of title has been a primary concern for registered respiratory therapists in Ontario since the HPLR began. To ensure proper identification of an acceptably trained respiratory therapist, and therefore also ensure public safety, an accurate title is key.

Just prior to when the blueprint for regulation of Ontario's health professions was distributed in January 1989, we were informed that the blueprint would not include the term "registered" in any profession's restricted title. Although we were not comfortable with this, it appeared that the door was closed on that issue. However, at a briefing immediately preceding the first reading of the Health Professions Regulation Act, 1990, and the profession-specific acts, we were informed that nursing had been given "registered" as part of its title. Clearly consideration should be given to other professions to include "registered" as well.

In providing health care, Ontario health care facilities primarily employ registered respiratory therapists. However, some duties are performed by on-the-job trained personnel who function under a variety of titles, such as respiratory therapists, respiratory aides, respiratory therapy assistants, non-registered respiratory therapists and respiratory technicians. Therefore, a second level of respiratory care practitioner does exist. Although our Canadian schools have no recognized training program for this, the United States does.


Again, a registered respiratory therapist is a graduate of an accredited educational program who has successfully passed the Canadian Society for Respiratory Therapists registration examination. The term "registered" denotes that a specific level of prescribed education has been achieved. Just as the titles "registered nurse" and "registered nursing assistant" provide identity and delineate a level of education, so does the title "registered respiratory therapist."

We have no desire to see any unregistered care provider put out of a job. Rather we want the specifically educated and skilled practitioner easily distinguished by the public at the bedside by the title "registered respiratory therapist." We see our previously proposed limited licence to practise covering non-registered care givers as they provide a clearly defined list of specific duties in a given health care facility.

Both medical laboratory technologists and medical radiation technologists are referred to as RTs. The use of "registered" and the initials RRT provide clarification for the public in identification of various health care professionals. We feel it imperative for the protection and the awareness of the public that the restricted title be changed to read "registered respiratory therapist."

I thank you for the opportunity to present these data before you this morning and I welcome any questions.

The Chair: Thank you very much for your presentation. I have a request from the parliamentary assistant to clarify.

Mr Wessenger: Yes, we have a request to clarify with respect to the title matter by ministry staff.

Ms Bohnen: Under the bill only members of your college will be permitted to use either the title "respiratory therapist" or the title "registered respiratory therapist," because that is a variation of "respiratory therapist." There is nothing to stop your college from determining that. All members of the college should always use the modifier "registered respiratory therapist" and the abbreviation so that public awareness of what "registered respiratory therapist" means increases. It will not be possible for unregistered people, non-members, to use the title "respiratory therapist" in Ontario, so if your college is concerned about a group of practitioners currently using that title, then a means will have to be provided, and is provided within the structure of the legislation, to create a class of membership for the less than fully qualified therapists.

Mr Owens: On the subject of the authorized acts that you propose in your presentation, are you currently performing these acts?

Miss MacDonald: Yes.

Mr Owens: So this in fact, if passed the way it is written, would be a restriction of your current practice?

Miss MacDonald: Yes.

Mr Owens: Do you know of any reason why these issues or these acts were left out? Was it simply oversight or is there any rationale?

Miss MacDonald: We had significant discussion on a number of these items with the HPLR group. Myself personally, I have been involved in it on behalf of the RTSO over the nine years of the history of this project. We were very surprised when it came out, in particular that procedure beyond the dermis was not covered, because some of those things are specifically currently validated medical acts. Again, we felt that the road was blocked, that the discussion had to end there and that our next avenue where I should bring this forth for consideration would be at this particular venue here, with the standing committee and the public hearings.

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

Mr Wessenger: Yes, I would like to have ministry staff clarify this matter.

Ms Bohnen: The review's intention and the government's belief is that the controlled acts currently specifically authorized to this profession reflect current practice and that those additional invasive procedures which has been mentioned, like arterial puncture and so forth, are currently and will continue to be done under medical direction as delegated controlled acts in this legislative structure. There is no intention to limit the sphere of activity or the hazardous procedures that respiratory therapists are now engaged in.

The issue, I think, is the more narrow one of which legal device is most appropriate given the setting, the nature of the activity and so on. They have proposed that it be permitted to members of their profession in essence through regulations under the act, which would specify the prescribed procedures they may do. The government's intention was that this be viewed as delegated authorized acts from a physician.

Mr Beer: You mentioned that you have been working on this for some nine years. I think members of the committee are reaching the point where they feel a medal should be struck for anyone who has managed to stay with this throughout that whole period.

I just want to go back to your scope of practice and your point about the "education of the public in order to" -- yesterday in Ottawa we also had a group that was talking about health promotion -- but where that sort of sense of education is involved. I take it that you want this here in order to underline that particular function. There is nothing that would preclude you from doing it, but this would give it a greater place, so to speak, in your scope.

Miss MacDonald: And it is something we do. The example I gave verbally of the lungmobile is something that is outside the institutional setting, but it is also something we do every day in counselling our patients and preparing them to go home. There is an education component to a great deal of our everyday practice. We thought to leave it out was not fully illustrative of what we did, that we have that as not only our day-to-day practice, but the things we do outside that help to increase the awareness of the public.

Ms Haeck: On page 7 of your brief you raise an interesting point under rationale: "Registered respiratory therapists working in health care facilities where their role includes diagnostic services" in relation to allergy challenge testing. Could you explain the diagnostic services you would perform in an allergy testing situation?

Miss MacDonald: Yes. Challenge testing that we participate in is actually determining whether the patient has a reactive airways disease, so we are actually challenging them by having them inhale a substance that is known to cause a response in certain individuals. Based on their response to this test, it helps the physician determine whether they have, for instance, a reactive airways disease.

Ms Haeck: Okay. This is one test I have not had. I thought I had had them all. Let me just get some expansion from you on this. Basically it has already been determined by the doctor, or there has been some suspicion on the part of the medical practitioner, that there is a problem in this area and he or she then prescribes the test, an inhalation, be it essence of peanut butter or whatever. You provide a mist of this substance into the air passage and you provide a record of what transpires.

Miss Quintieri: Yes.

Miss MacDonald: Yes, a certain degree of response is considered indicative of a particular problem. To be more specific, one of the primary challenge drugs per se is histamine. It is known to help produce --

Ms Haeck: I have popped a few of the antihistamines.

Miss MacDonald: Yes. It can produce dramatic response in someone who is asthmatic, for instance. It is a known substance and if a response occurs to a specific degree it is indicative of asthma, for example, asthma being one type of restricted airways disease.

Ms Haeck: We have been bouncing around the ball of diagnosis and assessment for the last three and half weeks. As I have described it, it is trying to nail the jelly to the wall. How would you see that this is diagnosis as opposed to assessment?

Miss MacDonald: It helps the physician to diagnose. We do not diagnose. We are purely reporting the results of the tests we do. We are not preforming any diagnosis.

Ms Haeck: Okay. That is what I needed.

Mr Reid: We are providing diagnostic information to the physician to make a judgement call.


Ms Haeck: You are providing a portion of what they described yesterday in their presentation as one of the tests in that whole differential diagnostic process.

Miss MacDonald: That is right. Our practice is primarily clinical and/or diagnostic. Things like exercise stress testing, this allergy challenge testing and pulmonary function testing are diagnostic. We do a fair bit of diagnostic work, but we prepare the results for the physician to then look at and make the diagnosis.

The Chair: Thank you very much. We appreciate your appearing before the committee this morning. As I have told other presenters, if over the course of our hearings and deliberations there is additional information you think would be helpful to the committee, please submit that to us in writing by the clerk. Thank you for appearing today.


The Chair: I call next Mary McLelland. Please come forward. Welcome to the committee.

Mrs McLelland: Good morning. My name is Mary McLelland. I am the very proud mother of a five-year-old boy who was born with the physical challenge of cerebral palsy. His name is Sean Michael. Anyone who would suggest that I cannot continue to hear directly from my speech therapist about my son's speech diagnosis and follow-up therapy plans obviously has never walked in my shoes.

I am outraged. I am the one who has to live with a child who cannot crawl, sit, stand or walk by himself. I am the one who has to carry him and his manual wheelchair up two flights of stairs to reach his speech therapist. I am the one who does this most willingly and with the greatest pleasure, because this particular therapist is there for Sean and the achievement of his fullest potential. Why would I question the credibility of my speech therapist when she was recommended to me by my son's paediatrician? He obviously respects her work, and so do I.

Why would I go to his paediatrician when I do not even know if he has had time to read the initial assessment findings or the quarterly follow-up reports? How can I expect him to answer my questions as to the clarification of the therapy program, or tell him that the intense content will be too stressful for Sean and will accomplish nothing but frustration? His specialty is to diagnose and treat critically ill children. Sean is not sick. He is physically challenged and that his paediatrician has told me and has given me the correct terminology for his lack of gross and fine motor skills.

Our speech therapist's specialty is the development and implementation of the appropriate speech and language program for my son. We must work together as a team or there will be no progress. Sean must first trust me to make the right choice for him and then trust the therapist to allow her to work nose to nose with him, literally. I in turn must trust her personality, her educational background and her methods. She must trust me to know that I will reinforce what she has taught Sean at each session.

This essential aspect of our team trust can be clearly illustrated through the following example. Sean's type of cerebral palsy will never allow him to lose his startle reflex; however, he will learn to control it. Most children lose it at four months of age. Needless to say, anything or anyone that comes up to him from behind without warning or anything very noisy will cause his whole body to extensor, and he will then proceed to cry uncontrollably until the situation is explained to his satisfaction.

Sean started speech therapy at two and a half years of age. Due to the fact that our therapist is so excitable, outgoing and very keen about her work, the first three hourly sessions were lost to a crying, frightened little boy. I therefore suggested to her that she not come into the room for the start of the next session, but rather put a toy on the floor in the middle of the room that we could play with that would allow Sean to use what little vocabulary he had. She stayed out in the hall for 10 minutes and was finally able to hear Sean say his few words. She then crawled into the room and sat in one corner while we continued to play with the toy. All the while, Sean was keeping an eye on her.

The next session, Sean allowed her to sit next to him while she whispered her instructions to me. During the following session Sean was lifted by the therapist on to her knee. She had won his trust. I could now relax and together as a team we were ready to move ahead. Our speech therapist was secure within herself to believe in the fact that a mother knows her child best. As a mother, I need therapists who are willing to acknowledge me as something other than just his mother or, "She's only the parent," but rather, "She's an important part of the team."

As a result of three years of weekly sessions, Sean is now able to say hundreds of single words and a few three-word sentences. I will never be able to thank our speech therapist enough for all the man-hours, all the encouragement and all the energy, and most especially for all the late-night phone calls she received from a stressed-out mother who felt she was failing her son because she was burnt out. No physician could ever give this kind of consistent support to someone who seemed to be at the time a drowning mother.

Sean will start kindergarten this fall and so we must leave the direct services for the school system. We are actively looking for extra help, as the school system cannot possibly offer the number of hands-on hours we have become accustomed to. Therefore, please do not add to my stressful life by allowing untrained individuals to tempt me with their shingle. Only qualified speech and language pathologists can be permitted to use the title "speech therapist" wherever they choose to work.

Specially trained speech therapists deserve our respect for the many years of required education and the number of clinical hours they have accumulated. They should not be shrugged off or disregarded by anyone who one day wakes up with a bright-eyed notion to play speech therapist. This is real life we are talking about, not some temporary whim. If you pursue this line of wasted parent-physician time and the OHIP cost of doctor visits by also involving the physiotherapists and occupational therapists, then you will see me here for a second and third time.

Do me and other voters who have physically challenged children a favour: Leave the system the way it is. Do not change the direct services we already have with our speech therapists, and please protect us by enacting legislation that will restrict just anybody from calling himself or herself a speech therapist. They must be educationally qualified. In conclusion, please note that we do not need go-betweens, we do not need need more appointment bookings and we do not need to be part of a power struggle; however, we do need upfront, honest and detailed assessments by someone we can trust and who we know is there for the betterment of our children's future. Sean's speech therapist has become his trusted worker and friend. She is my lifeline. Do not pull the plug. Thank you.

The Chair: Thank you very much for a very thoughtful presentation before the committee. We have a request from the parliamentary assistant, Mr Wessenger.

Mr Wessenger: I would like to assure you that there is nothing in the legislation which would restrict the right of your speech pathologist to discuss the treatments she is giving to your son or the assessment of his condition. In fact, in the legislation the assessment of speech and language functions is given specifically to speech pathologists and that assessment includes the right to communicate that assessment and discuss the treatment with you. I can assure you there is nothing in the legislation that would change that relationship.

Mr J. Wilson: Mrs McLelland, although I would suggest you keep a copy of this Hansard and if you run into any problem mail it back to the parliamentary assistant, none the less I am curious to know how you first thought to go to a speech-language pathologist or a speech therapist and how at the present time, under current conditions, you would know whether that was a qualified person or not.

Mrs McLelland: She was recommended by the paediatrician.

Mr J. Wilson: Oh, she was recommended. Okay.

Mr Beer: This is along the same line, because it relates to the title. In your own experience, since you have been working with the speech therapist, have you come across other people who were pretending to be speech-language pathologists or other parents you were in touch with who have challenged children?


Mrs McLelland: Who pretended?

Mr Beer: Yes. Is that something that you as parents sense is out there and is confusing to you in making --

Mrs McLelland: I have to say, in all honesty, I am a very protective person. I have an excellent paediatrician, and any specialist who has been given to my son and myself -- as I say, if I joke, we have horseshoes around our necks -- has just been absolutely ideal. I have spoken to other parents who have unfortunately had trained speech therapists who are not there for their children. As in every profession, you have the good and the bad. But myself, as I said, I am very protective, so I have not met anyone who has pretended to be.

The Chair: Thank you for your presentation today. We appreciate your coming before the standing committee this morning. I know that because of your interest you will probably monitor the results of the committee. You should feel free at any time to communicate with us in writing or be very comfortable to contact personally any of the committee members or your own member of the provincial Parliament if you want to discuss the matter further.

Mrs McLelland: Thanks for your time.


The Chair: I call now the Ontario Teachers' Federation. I ask that you come forward. You have 20 minutes for your presentation. Please begin by introducing yourselves to the committee and we ask you to leave a few minutes for questions from committee members. I know you are very experienced at appearing before legislative committees, but I try to give everyone the same information so that we are clear on it. Please begin your presentation now.

Mr Poste: I am Ron Poste, the president of the Ontario Teachers' Federation. I am pleased to have assisting me this morning Margaret Wilson, our secretary-treasurer, and Ruth Baumann, one of our executive staff members. Contrary to your remarks, I am not used to presenting to committees like this. I became the new boy on the block last week.

The Chair: Congratulations. Nobody here bites. We are actually in a very good mood this morning. I notice everybody is smiling.

Mr Poste: We certainly do appreciate the committee's altering its schedule to hear from us at this time. We had a conflict and were unable to present when we should have done so. We are pleased to be able to appear before you and present concerns of the Ontario Teachers' Federation about Bill 43.

The federation represents over 126,000 teachers in the publicly funded elementary and secondary schools of the province. We have also discussed our brief with a subgroup of our members, the Ontario School Counsellors' Association. They hoped to be represented this morning, but a funeral took their representative off on a more important task. We have discussed our brief with them and they concur with the points we are going to present.

We recognize that it is intent of this legislation to protect our citizens from harm and misrepresentation, but it creates restrictions within the educational environment which cause us concerns. We would like to outline these to the committee at this time.

Our concerns are not solely within the Ontario Teachers' Federation. When the first draft of this bill was introduced, we discussed our concerns with the Ministry of Education. The concerns were also felt by that group, and appended to our submission is a letter from Robert Mitton, the Deputy Minister of Education, to the Deputy Minister of Health, expressing some of the concerns of the Ministry of Education that were initially brought up with the legislation.

I think our concern can be summarized in the paragraph that begins at the bottom of page 1. There is considerable overlap between health care, social services and education in our society. The legislation presently before the committee, with its emphasis defining and distinguishing the functions of various health care providers, must be reconciled with the increasing thrust for better integration of services and for better interdisciplinary co-operation.

We have serious concerns regarding the very general definition of diagnosis as it is contained in paragraph 26(2)1 of the bill. It is my understanding that the members of the committee do have the legislation, and our concern, if you wanted to focus on that, is on page 8, in that particular part. The communication of a conclusion identifying why a student is behaving in a certain way seems to be incorporated in that definition, and that, we believe, is going to detract from the quality of service that we have been providing within education.

Guidance counsellors, special ed teachers, phys ed teachers, vice-principals, principals, teachers trained in children's educational and psychological needs, often called psychometrists, do make judgements about the performance of students. The education legislation itself does require that assessment be done before a pupil can be identified as exceptional. We are required as teachers to "assess students' particular social and emotional needs and make recommendations for referrals to or consultation with other staff or community agencies." It is very difficult, as we see it, to distinguish between what is a mental health issue and what might be considered to be an educational issue.

We are also called upon to counsel students and families. The teacher or guidance counsellor quite often will refer students to a specific agency or service provider for more in-depth consultation. We have a concern that diagnosis as it is defined in the legislation now will prevent or stop some of the activities that have been going on.

Within the province, small communities do not have full reference to the wide range of services. People involved in education in these small communities quite often are called upon, as trained professionals, to do some of this consultation and referral. We have a concern that the legislation will jeopardize that service for small communities.

Related to that in small communities but not directly within education, and perhaps you have already heard of it, is our concern that much of the advice given by pastoral counsellors might also be terminated by this legislation.

Schools now, with the integration of exceptional students into them, quite often could be termed health care settings under this legislation. Our question is basically, what restrictions will apply to these services, particularly in the area of speech and language assessment, if they are provided within the school? Will this become a health care setting under this legislation? The program is there. The traditional involvement of schools is changing to provide much more in the area of health care, and we do not see the interface between what is now happening and what is anticipated under this bill.

If you track it through from the educational point of view, and again I would refer you to the appendices of our presentation, policy memorandum 81 focuses specifically on the provision of health support services in school settings. This was the start of bringing some facets of health care into the educational environment. Further clarification was given in 1989 in a memorandum indicating that it was acceptable within the school setting to perform clean catheterization and also shallow surface suctioning by trained personnel, but not necessarily personnel who had been trained to the extent that was traditionally expected. We now have teacher assistants who are trained and able to undertake these particular procedures with students.

As we read the proposed bill, this would prohibit the continuation of that and require that the more fully trained health service professionals, nursing assistants, VON, health unit staff, would take over that function. We really wonder if that is the intent of this particular bill.

One of the major concerns we have is an interdisciplinary approach to the provision of service for students. The Ontario Teachers' Federation applauds many of the moves of this past year to try to integrate the provision of services between or among intergovernment agencies. In the report of the Advisory Committee on Children's Services, Children First, this seemed to be one of the major concerns addressed. It states: "Services are too fragmented, overspecialized and overburdened...The provincial government should promote models of service integration and collaboration that simplify access to service and rationalize the roles of our limited resource of trained specialized service providers."

We believe we have some of these in the schools. Our concern is that this focus, which would tend to perhaps even more fragment, would remove a service that our children now have.

I think our major concerns, in summary, can be focused on that definition of controlled act, and as we read it, how does it apply in the schools? If it does have the effect of fragmenting services rather than fostering more integrated approaches, then in our opinion our children will not be as well served in the future as they are now.

The federation does ask the committee to consider several important things, and I guess I would emphasize the point made by the previous presenter. It is important in this province that legislation prohibit misrepresentation. It is important in our mind to confine the diagnosis to an area where there is expertise, and perhaps the law might want to focus on confining medical diagnoses but at the same time acknowledge the legitimate diagnostic role of professionals who have training in other areas. It is important, I think, that all professionals recognize the limit of that training and stay within it. If that happens, then I think our people are well protected.

We would also advocate that the present prohibitions on the practice of medicine without a licence be maintained.

That I think summarizes our presentation, and if there are specifics that committee members would like to address, we would be only too happy to expand on them.


Mr Jackson: I appreciate receiving this detailed brief and as well the response from the then Deputy Minister of Health Barkin to Deputy Minister of Education Mitton's letter. When I read the Barkin letter, I see clearly the suggestion that some of your concerns, in their opinion, have been met, but "it may be possible to resolve at least some of the anxieties of unregulated practitioners through amendments to the wording of the controlled act."

You have laid out three items for our consideration on page 7. My question is, have you had any opportunity to dialogue with the Ministry of Health or Ministry of Education with respect to preferred options or potential amendments?

Ms Baumann: No, we have not. At the time that we worked with the ministry on the letter that went from Deputy Minister Mitton to Deputy Minister Barkin, the approach that was being looked at was some kind of an exemption. As the months went on and the legislation changed and we took another look at it, we were not sure that in fact that remained as a sensible option, that you could just exempt a whole field as big and in its own way as ill defined as health probably, that is, education, so we began to try to look for something that might address the need of the protection of citizens while at the same time not overregulating.

Mr Jackson: As I noticed in the dates of the letters, it is clear that the government tabled some amendments post-April 26, the date of the letter from the Deputy Minister of Health. Have you read the amendments and do you see any comfort in them, and if not, have you had an opportunity to directly contact either of the ministries since the tabling of those amendments?

Ms Baumann: We have spoken with the Ministry of Education. We do not have the letter from Dr Barkin to Mr Mitton. We know that such a letter did go. We know that the basket clause, as it is referred to in the letter from Mitton to Barkin, is no longer in the legislation, and we were quite pleased to see that go. But the general concern in terms of the provision, particularly of counselling and educational assessment services within the school, was one that, in my conversations with Deputy Minister Mitton's executive assistant, I think we continue to share with them.

Mr Jackson: Madam Chair, if I may, just for purposes of the Hansard record, the letter I was quoting from was just tabled with the brief but was not part of the brief that we just received from the OTF. That is a memorandum from Linda Bohnen, counsel for this legislation, from the Ministry of Health. We have just received it now and perhaps we can share that as well with the deputants, and I should thank Ms Bohnen for having that here today for our consideration.

Mr Beer: I also shall be referring to the letter from Dr Barkin and it would be a question to the parliamentary assistant. It is set out that "no person shall perform," etc, "in the course of providing health care services," and then in the different controlled acts there is another one, the holding-out clause. In the letter stress is put on the fact that, look, we are only talking about people providing health care services, yet if one thinks of what happens within a school setting and certainly the discussion around children first and where that might go, mental health and so on, one can see where that starts to get perhaps a bit of a murky line.

In talking about the amendments at the end that Mr Jackson referred to, and the point made earlier that the legislative drafters wanted to anchor that clause to something specific, what would be the difference in subsection 26(1) if it did not contain the phrase "in the course of providing health care services" but was more generic? What is changed in that?

Mr Wessenger: I will ask ministry staff to respond to that.

Ms Bohnen: I think the issue of the language in the course of providing health care services has a very different significance in relation to the controlled acts than it does in relation to the holding-out clause or the title protection clause. It is important, we believe, to confine the controlled acts to the delivery of health care services because we can all imagine, I think, many examples in which people's bodies are invaded or things are done which would otherwise inadvertently be prohibited or restricted to regulated health professionals. The government has no desire at all to regulate those activities under this legislation.

I think that the concerns being raised by the OTF and the Ministry of Education have to do, first of all, with not inadvertently precluding teachers and other education professionals from performing assessment activities, and that is the diagnosis-assessment issue you have heard many groups talk about. Then, when we get into another issue they raise, which is that many health services, or things that look like health services, are provided by teachers' aides, speech-language pathologists, occupation therapists, whoever, within the school system, that is another whole set of issues.

The most pressing one being raised would be dealt with by the way in which attendant care services will be provided. I do not know if this group would be aware of the fact that all Health ministers who have participated in bringing this legislation forward have expressed and confirmed their intention to make exceptions for the provision of attendant care services such as the suctioning, intermittent catheterization, and so forth that you refer to.

Mr Beer: Can I just follow up then? One could look at what it is that teachers may do in the course of a regular day by looking at something under section 28. Right? I do not want to misinterpret what you are saying.

Ms Bohnen: I think what I am saying is, the kind of possible amendment that Dr Barkin was referring to was the same possible amendment the minister was referring to when she came before this committee and said: "I know there are outstanding concerns about diagnosis-assessment. I hope the committee will guide me in making an amendment in that area." It was the deputy minister's view, and I think it is now the OTF's view, that just creating a statutory exception for education professionals would probably raise more difficult issues than it would really solve, and it was not the best way of approaching the issue.

The Chair: Thank you for appearing before the committee today. We appreciate you making such an excellent presentation. If in the course of the deliberations of the committee there is additional information you think would be helpful, I know you are aware that you can communicate with us through our clerk. Thank you for appearing today.

Is Bill Burns here? Mr Burns's appointment time is now, 11:50. If there are any questions of the parliamentary assistant, we could use a few minutes to do that and give Mr Burns a few minutes to arrive, if he is going to show up. Are there any questions of the parliamentary assistant or ministry staff?

Mr Beer: One of the issues that has often come up has been that certain things will be done under regulation. When we are meeting with officials that week of September 16 and 17, I would like to have a better understanding of why certain things would be best placed under regulation and others within the legislation itself. Some of the concerns that have been expressed are around a misunderstanding of, I suppose, the standing of regulations as part of the legislation. It would be helpful to us if we could see that issue a little more clearly, if I could just note that.

Mr Wessenger: I was just going to add to that, perhaps we should include the aspect of delegated acts as well in that, so we could see it as a whole picture.

Mr Beer: Yes. In effect, I guess it would be anything other than the specific legislation which needs to be drafted, drawn up, whatever, and it would have a direct impact on the groups we are going to be regulating.

The Chair: The request is noted and we will ask that that be included during the committee hearings on September 16 and 17. I should note -- it was mentioned in a question to the clerk -- it is my understanding that on the day Mr Schwartz makes his presentation, which is the morning of September 16, there will be a lot of people interested in attending the session that day. I am wondering whether there is a larger room available.

Since it was brought to my attention I thought I would mention it to committee members. The clerk says that she will check and see if there is a larger room with more seating. It would be unfortunate if people had to stand or felt they were not welcome. Certainly we want to make everyone as welcome as possible to these hearings. The level of interest, I think, is very high.

Mr Burns is still not here. The committee will stand in recess for five minutes and give Mr Burns a chance to arrive.

The committee recessed at 1153.


The Chair: The standing committee on social development is now in session. It is 12 o'clock. Mr Burns has not shown up and therefore has forfeited his time before the committee.

The committee recessed at 1200


The committee resumed at 1400.


The Chair: I would like to call the Ontario Association of Registered Nursing Assistants.

Mrs Steffler: My name is Verna Steffler and I am the executive director of the Ontario Association of Registered Nursing Assistants. With me I have Audrey Shaw, who is the president of OARNA, Gail Bennett, who is the executive assistant of OARNA, and Margaret McDavid, who is the secretary-treasurer of OARNA.

OARNA is a voluntary professional association with about 5,000 members and we are deeply concerned about this legislation. Let me begin by saying that in general OARNA is very supportive of the Regulated Health Professions Act. We liked the open process that was used to develop it and there is no question a great deal of very hard work went into preparing this historic legislative package. Everyone who participated deserves congratulations, and for the most part we are very happy with the results.

However, I have to tell you that OARNA is very much opposed to Bill 57, the act which keeps registered nursing assistants together with registered nurses under one college. In our view, this bill is just like forcing a bad marriage, one that has not worked well in the past and will not work well in the future.

We have tried to put our case to the government, but to be fair I do not really think the minister has had the time to review the implications of this bill, so we are counting on each and every one of you, in all three political parties, to help avoid an unjust and unworkable situation.

As far as we are concerned, there is only one solution that makes sense: RNs and RNAs should each have their own college. That is what we hope you will recommend in the interests of fairness. We do not want to hold up the legislation, but we do need your help in correcting a bad situation.

I thought perhaps it would help you to understand our position if I talked a bit about registered nursing assistants, because I know there could be some confusion about what we do, especially when you compare our role with the role of a registered nurse in our system.

Actually the distinction is quite straightforward. RNAs provide basic nursing services. I am talking about practical, hands-on nursing care in institutions and in the community. By contrast, registered nurses deliver a much broader set of services, care that often involves more complexity and more technical expertise. This is appropriate. RNs train longer and have a wider scope of practice than RNAs.

RNs and RNAs often work in the same places, but contrary to popular opinion RNAs do not always report to an RN. Sometimes our supervisor is a doctor or another type of health professional, or an administrator. Sometimes the supervisor is another RNA.

In most parts of North America, registered nursing assistants are called licensed practical nurses. They are considered to be a separate profession and are not regulated with or by registered nurses. In Canada, licensed practical nurses in Alberta, Saskatchewan, Manitoba, Quebec, New Brunswick and Prince Edward Island are self-regulating. In fact, Ontario is the only province that regulates our profession together with RNs in one regulatory body.

Based on our experience, we believe that this is a terrible mistake. We have had lots of experience with clustered regulation and we know that it cannot work when the professions involved disagree about their respective roles in the health care system. That in a nutshell is our problem with being regulated in the College of Nurses of Ontario. This should not be taken as an attack on the college of nurses. We do believe that the college tries to maintain its public interest perspective. However, there is no getting away from the fact that sometimes it makes decisions that favour the RN over the RNA, even when the issue has nothing to do with public protection.

RNAs are able to deliver essential services at a very competitive price. Our profession is one of the most important keys to a more cost-effective health care system. However, in our view, being jointly regulated under one college has stood in our way and will continue to block the development of our profession as a cost-effective alternative to the registered nurse.

The truth is that our respective professions compete with one another and under the current structure of the college it is an unfair competition. Let me explain. There are about 105,000 RNs in Ontario and about 35,000 RNAs. The representation on the college council reflects this distribution. The current CNO council has 32 members; eight are public representatives, 16 are RNs and eight are RNAs. The proposed law would change the composition of council to increase the proportion of public members, but even so, RN council members will continue to outnumber RNA members two to one.

From our perspective, this structure does not look like self-regulation for RNAs at all; it looks like the regulation of RNAs by RNs. We do not think that RNs should have this kind of power over our profession.

Staffing patterns and the focus of work at the college also reflect the inequality between our two professions. RNA membership fees constitute about 25% of the CNO budget, but only about 13% of its total revenues are actually spent on RNA affairs. Of the 19 professional staff working at the college, there are 16 RNs but only three RNAs.

RNAs are a separate profession. We say that even though our profession learns some of the same things and performs some of the same duties as the registered nurse.

The truth is that the knowledge base and scopes of practice for many health professionals overlap to some degree. RNs, RNAs, orderlies, health aides, midwives and ambulance attendants learn some things in common and perform some of the same job functions, but that does not mean they all ought to be regulated under the college of nurses. Nowadays, registered nurses perform many functions that used to be restricted to doctors only, but no one thinks that RNs ought to be regulated by the College of Physicians and Surgeons of Ontario.

The issue of self-regulation hinges on the risk of harm to the public. This legislation has identified 13 types of health care activities that could result in harming the public if carried out by unqualified personnel. Called "authorized acts" in the RHPA, these potentially harmful interventions have been allocated among various health professions on the basis of their education and competence to handle them. And so, while it is safe for an RN to perform all of the job functions of an RNA, the reverse is not the case. Similarly, a dentist is competent to perform all the functions of the dental hygienist, but not the other way around.

On the same basis that dental hygienists are considered a separate professional group under this legislation, we hold that RNAs belong to a separate profession, one that is related to but distinct from registered nurses.

Bill 57 does not recognize our separate status as a distinct profession, but other nursing organizations do. The Registered Nurses' Association of Ontario, for example, believes we are so distinct we should not be called nurses. Both RNAO and the Ontario Nurses' Association, Ontario's largest nursing union, have argued for greater distinctions between RNs and RNAs in the standards of practice. Both positions are consistent with the idea that RNAs are a separate profession.

Unfortunately, Bill 57 perpetuates an injustice. It allows one profession to dominate another by pretending that we are all members of the same group while maintaining the need to have two different categories.

We do not think this adds up to self-regulation for RNAs, particularly in view of the fact that RNs and RNAs compete with one another in the marketplace for jobs. This reality can and does influence the decisions made by the college of nurses.


The college of nurses makes critical decisions affecting our profession. They decide about our standards of practice, our competence to perform authorized acts, and our access to training. Because RNs outnumber us on council, and because they have more education and more status than RNAs, whenever the interests of RNs and RNAs collide, RNAs are likely to lose. Let me give you an example. Over the years physicians have asked the college of nurses to allow RNAs to administer intramuscular injection. Until the publication of their 1990 Guidelines for Decision-Making, the college always refused. Now they say it depends on the client population. For young, healthy schoolchildren the answer was yes. For the frail elderly the answer continues to be no. We do not think this decision makes sense. RNAs can administer subcutaneous and intracutaneous injections; why not intramuscular ones too? The training required to give all three types of injections is virtually the same.

We think this decision by the college was primarily driven by marketplace considerations, not the public interest. We do not think it has anything to do with protecting the public from harm. By making it impossible for RNAs to give intramuscular injections, the college was protecting jobs for RNs and adding unnecessary costs to the health care system.

Let us look at another example. Some years ago, OARNA was trying to promote the idea that foot care ought to be part of the RNA basic educational program. For two years we got nowhere at all in our discussions with the college. The CNO only changed its mind when an influential chiropodist from Britain and the Ministry of Health intervened on our behalf.

A fundamental principle of self-regulation is the idea that one professional group must not dominate or dictate to another, but that is what will continue to happen unless RNAs have their own separate college.

During the review conducted by Alan Schwartz, it was quite clear that RNAs, as a professional group, qualified for separate self-regulation. We met each and every one of the government's criteria. In fact, we were actually told at one point that the review committee was going to recommend a separate college for RNAs. We were very disappointed when it did not happen.

My presentation here today has focused on the main reasons why Bill 57, An Act respecting the Regulation of the Nursing Profession, is unfair and unworkable. I want to emphasize that your decision about this is primarily a political decision, not a bureaucratic or technical decision.

I hope you will agree with us and that you will recommend that:

1. The government withdraw Bill 57 and instruct the Minister of Health to draft two new bills providing for two separate colleges, one for RNs and one for RNAs, who should be called registered practical nurses.

2. The government refer to the Regulated Health Professions Advisory Council for technical advice about an appropriate scope of practice for RNAs, and our competence to perform authorized acts.

3. Finally, that RNs and RNAs continue to be regulated under the Health Disciplines Act until such time as the new bills are passed and proclaimed.

Please note that it is not our intention to hold up the passage of this important legislation. We believe that by adopting these recommendations the rest of the legislative package can and should go forward.

Although this presentation has concentrated on the issues of greatest concern to us, OARNA does have a small number of other changes to suggest with respect to this legislation which are contained in our submission entitled Other Issues of Concern.

One of the most important to us is our title. We want to see the word "registered" in front of the term "practical nurse" whenever it appears in the legislation. In several places in Bill 57, the word "registered" was omitted, probably just by accident.

Another issue we want to challenge is the government's amendment to Bill 57 which strikes out "on the order of a qualified person" and replaces it with "on the order of a member of the College of Physicians and Surgeons of Ontario."

We think this amendment is contrary to the intent of the legislation. It would mean, for example, that a midwife or a dentist could not give orders to a registered practical nurse for certain types of medication. We do not think this change makes any sense and urge you to retain the original wording of the section.

I want to thank every one of you for listening to our presentation. If you have not already done so, I want to urge you all to read the brief called "A Question of Fairness" before coming to a final decision. It gives much more detail about our case for separate self-regulation for RNAs.

Mr Owens: Thank you for the excellent presentation this afternoon. I gather your main concern with the legislation, other than the number of points you raised towards the end, is the issue of not receiving your own college. I am wondering, in terms of fulfilling the intent of the legislation, which is to open up the medical profession to the public, how would the public benefit by you folks having your own college rather than being regulated under a singular college as you are now?

Mrs Steffler: There are a few answers to that one:

A Question of Fairness points out the fact that our scope of practice is being held down or changed as the will so desires, which does not allow the profession to meet the needs of the public. With two separate colleges, I think the public would know who to approach about what. Each profession arose on its own, and each profession would have a working relationship with the other at arm's length, instead of our profession being more or less being stymied by another profession.

Mr Owens: In terms of how it works in the other provinces that are regulated or have their own separate colleges, how are the relationships between the different types of nurses, the RNs and the LPNs?

Mrs Steffler: I will let Audrey respond to that. She is president of our national association.

Ms Shaw: Just recently, three years ago, Saskatchewan achieved self-regulation apart from the RN profession, and a year before that Alberta did. There are three other provinces that have self-regulation and their own separate college, and what we have found with Saskatchewan and Alberta -- we monitored what happened after they separated and formed their own college -- is that we noticed that the relationship between the two professions actually improved, that they got along a lot better because they were on a level playing field. You have liaison meetings with them to discuss issues of mutual concern within the health care system. You speak and have mutual respect for each other and meet as equals, whereas being within the same college creates a conflict.

You mentioned, when Verna answered the first question, that the mandate of a self-regulating college is to protect the public. If you have two professions that cannot agree and there is conflict then it will interfere with that mandate. It cannot help but interfere. We are all human beings. If you have a separate college for RNs and RNAs, then the focus can be on that mandate of protecting the public interest and you will not have the conflict of the two professions.

Mr J. Wilson: Thank you very much for a very good brief. I was just wondering what explanation you have been given, if you have been given one, from the review committee as to why it did not recommend a separate college for RNAs, given that other provinces have moved in that direction.

Ms Shaw: The reason given to us was that we did have representation at the College of Nurses of Ontario and that we had a voice there. We do have a voice there and we do have representation, period, but we do not have self-regulation. We are regulated by the RNs. Right now the college council is 16 RNs, 8 RNAs, 8 lay people, and the proposed new legislation would be 17 RNs, 9 RNAs and 11 lay people. To me that does not look like a self-regulating system, especially for RNAs.

Another reason given was that dental hygienists, who are a much smaller body than we are -- we are the second-largest profession -- were given a separate self-regulating body, there being a conflict because they were hired by dentists and we were hired by institutions. I have yet to see an institution hire a person. It is the person within that institution who does the hiring. Historically, at most times within the nursing department, it has been the director of nursing who has the input, or the unit manager now because it has been decentralized in a lot of hospitals. It is the patient care manager who has the input on who gets hired and that person just happens to be an RN.


Mr Wessenger: I would like to have the ministry staff give some explanation of the reasons.

Ms Bohnen: I think, Mr Wilson, your question was why did the review not recommend a separate college. The fundamental reason for the review's recommendation, as we understand it, is that nursing is one profession. The review did not believe there was a distinct scope of practice particular to the registered practical nurse as contrasted to the registered nurse; rather, there was one profession with two levels of practitioner.

The Chair: We have 30 seconds remaining and I have one additional question.

Mr Beer: It follows along with respect to the scope of practice. Within 30 seconds, what would be the fundamental difference there? You have referred to your scope of practice. How would you define the RNA's scope of practice vis-à-vis that of the registered nurse?

Mrs Steffler: I think we are trying to point out that there is an overlap with everyone. Whatever the RNA does, the RN can do, but also if you take a look at what medicine does, you can also say the RN can do a great deal of the doctor's scope of practice. I think what we find through this whole health professions review is that everyone has a degree of overlap with everyone else. If we did not, we would not be under a Regulated Health Professions Act, would we?

The Chair: I would like to thank you very much for your presentation today. I know you are aware that if there is additional information you think would be helpful for members of the committee, you will submit further information in writing through our clerk. We appreciate your coming before us today.


The Chair: I would like to call next Carol Kushner.

Ms Kushner: My name is Carol Kushner and I am a consultant to a number of health care organizations interested in this legislation, but I am here today as a private citizen with a particular interest in quality assurance.

As some of you may know, I participated with Cathy Fooks and Michael Rachlis in a research project in 1989 that looked at Canada's regulatory bodies and what they were doing in terms of the quality of professional practice.

Specifically, we looked at five professions: medicine, optometry, nursing, pharmacy and dentistry. We discovered that although each and every one of those organizations did for-cause investigations of quality, that is, investigations that were triggered by complaints, only about half had any kind of proactive quality assurance program.

There were quite a few reasons to explain why this was the case, why so many were uninvolved in doing routine audits, including reasons like lack of interest and lack of resources, but the main reason was that many of them lacked the legislative authority to do this kind of routine assessment. I am glad to say that, when it passes, the Regulated Health Professions Act is going to clearly stipulate this mandate for colleges in Ontario. I think that is a major step forward.

That being said, I do have a couple of concerns about the smooth operation of quality assurance programming in Ontario even with this historic legislation.

The colleges governed under Bill 43 are subject to identical terms and conditions, but they are not all equal. They differ quite a bit in terms of their size and in terms of their resources. I think it is fair to say that some of the very small colleges are going to have a very difficult time carrying out meaningful quality assurance programming on their own. The truth is, I would guess that only about a handful of the colleges established under this legislation will be able to develop good, stand-alone programs.

It seems to me that if the government is serious about quality assurance programming, we need to recognize that at the moment the infrastructure to do that simply is not there for the vast majority of health professions. Take, for example, the problem associated with developing standards.

As you probably know, quality in health care is not just a matter of making sure the care is well executed. I do not mean to underestimate the importance of that. It is terribly important. We do need to know that whatever is being done is done well. But high-quality care also depends on making sure the practitioner is making good decisions. Usually there are choices to be made about alternative types of therapies and interventions so that quality of care also means doing the right thing, making the right choices.

People vary an awful lot in the way they respond to treatment and we cannot always assume that just because we get better following a treatment, we got better because of what the health practitioner did to us or for us. It is just not that simple. Only scientific research can tell us which therapies work best and for which kinds of people. Unfortunately, most of the time this kind of scientific evidence simply does not exist.

This was a surprise to me when I started to study health sciences research and it may be a surprise to some of you, but the fact is that most of the time health professionals really and honestly do not know whether the interventions they use every day work or not. This is true even of medicine which is clearly, I think you would agree, the most scientific of disciplines. Some 80% of therapies they use have never been subjected to systematic rigorous scientific evaluation.

Only technology assessment can answer these kinds of questions, and for the moment most technology assessment focuses exclusively on medical practice, what physicians do. We do not know what the effect of nursing care is or other health professional interventions. So the first structural barrier I see to meaningful quality assurance is the lack of scientific evidence on which to base standards.

The second structural barrier has to do with how much it costs to run good quality assurance programs, and for this I want to refer members to experiences from the province of Quebec. Quebec is the only place in Canada where every profession is required to conduct professional inspections. I think in the research I mentioned earlier each of the five professions we studied had some form of quality assurance program.

In 1984, for example, physicians in Quebec spent about $1 million -- actually over $1 million -- on their professional inspection program. It represented more than one-third of the total expenditures of the Corporation professionelle des médecins du Québec. In the same year, Quebec nurses spent almost as much as doctors, some $875,000. However, the government of Quebec explicitly recognizes the financial inequality of professions by giving out grants to support professional inspection programs. Sometimes these grants actually pay for most or even all of the costs associated with QA. A table is attached to my written submision that will give you some more information about what happens in Quebec.

I think it is fair to say that without some kind of similar program here in Ontario, many colleges will fail to implement good QA programming. They will not be able to live up to the requirements of this legislation. So the second structural barrier to quality assurance in Ontario is financial.

Finally, I want to draw your attention to the enormous potential for cross-pollination among and between health professions. Quality assurance is a rapidly developing field and we could avoid a lot of wasteful duplication of effort by making it easier for colleges to find out who is doing what, what is working elsewhere, and helping them to adapt that information to their own circumstances. I do not think that means QA has to look alike in every college, but we do need some mechanism for facilitating information sharing.

So the third structural barrier to quality assurance is the lack of a mechanism for information-sharing and co-ordination. All three structural barriers, scientific, financial and informational, could be overcome by setting up a permanent secretariat with a mandate to help colleges establish QA programs.

Specifically I think this secretariat could give advice about research evidence for standards setting. It could develop a centralized data bank and other resources to make it easier for colleges to organize their own data collection activities. It could provide expert advice about analysis and alternative interventions.

It could also provide financial assistance to colleges too small or too underfinanced to go it alone, and it could become a vehicle for information sharing and co-ordination.

Another point I want to make has to do with the term "quality assurance" itself. A lot of professions I have been talking with are very worried about this term. They think it gives rise to a lot of unrealistic expectations. They are not sure that anyone or any organization can assure quality and they would like the wording changed. They might be right, I am not sure, but what I can suggest, if there is a wording change in the offing, what it might be.


It seems to me that while it may not be possible for the college to assure quality, it is certainly possible for the college to assess and improve quality through its activities, and that might be the kind of wording change they are looking for.

I think there are a couple of things missing from the provisions for quality assurance within the legislation. One has to do with annual reporting. All of the committees are required to give an annual report and there is no detail in the legislation about what ought to be in those reports. With respect to quality assurance, I think this is a failing. Number one, I think the proportion of members inspected or somehow touched by quality assurance programming needs to be reported in the annual report. In addition, I think the expenditures on quality assurance programming would give us an indication of who is doing what and to what extent.

The weakest part of quality assurance is, when you find a problem, what the heck do you do about it? How do you change behaviour? We do not know very much about that. We try certain things, but we are not sure they have an effect. So having some kind of report on what we have done when quality problems were uncovered and how effective it was would be very helpful in monitoring the development of quality assurance programming.

Finally, if colleges are going to get involved in professional inspection into the quality of practice with their members, then the colleges have an obligation to let members and the public know what criteria are going to be used to evaluate their performance. I believe both of these concerns ought to be addressed in the procedural code.

There is lots more I could say about quality assurance but my time is up.

Mr Beer: Thank you very much for focusing on this particular issue. It has come up but you have really looked at it in some depth. Your proposal about a secretariat, is that something you would see being perhaps connected to the proposed advisory council or totally separate?

Ms Kushner: No, in fact, I think it could make a great deal of sense to have it attached and reporting to the advisory council. It seems that way there could be advice flowing up to the minister and flowing out to the colleges and structurally that would fit.

Mr Beer: Does Quebec have that kind of structure?

Ms Kushner: They have a slightly different organization in that they have a professional code that governs not just health professions but lawyers, accountants and the whole ball of wax. They have an Office des professions du Québec which is established within the terms of that professional code. The functioning of the office, although it does grant subsidies, has not been terribly helpful in facilitating the kinds of things I was discussing here. They have been very arm's length.

The Chair: Thank you very much for an excellent presentation. The committee appreciates your coming today. You are aware that if there is additional information you think might be helpful to the committee, you can submit it in writing to our clerk. Most of the members of the committee know you are the co-author of the book Second Opinion, and that is just a little plug.

Ms Kushner: Thank you.


The Chair: I would like to call now the Speech and Stroke Centre. Welcome.

Miss Arato: My name is Pat Arato. I am the executive director of the Speech and Stroke Centre, North York. I have with me also Aura Kagan, who is a speech pathologist. I am not a speech-language pathologist but an administrator of a program that employs speech-language pathologists.

The Speech and Stroke Centre is a community agency which provides service to 100 members who suffer from aphasia. Aphasia is a language disorder that impairs the ability to communicate and is usually caused by a stroke. To help our members, we rely on speech-language pathologists who train volunteers to carry out community programs. I have attached further information about our centre as well as the brochure on aphasia, which I have here.

Although we support the principle of Bill 44 to regulate the profession of speech-language pathology, we are concerned about three aspects of the legislation, the restriction of speech-language pathologists from communicating their conclusions, the limiting of the act's title restriction to only people engaged in providing health care services and the lack of protection of the title "speech therapist" and the use of the term "doctor" by speech-language pathologists with a PhD.

Our first concern relates to the controlled act of communicating a conclusion. In the proposed legislation, speech-language pathologists are not permitted to perform this controlled act. We believe this restriction would affect the level of service we can offer our members and would not be in the best interest of individuals with aphasia. Currently all potential clients must be referred by a speech-language pathologist based on a professional assessment. This assessment is then forwarded to our speech-language pathology department. During a subsequent screening interview, further assessment is carried out to ensure that the client will benefit from the program. This information is shared with the aphasic individual and the family members so that a joint decision can be made together with a professional team regarding future participation.

If Bill 44 is passed as written, our procedures would have to change. We would no longer be able to have our speech-language pathologist discuss her conclusions with the patient. Instead, assessment results would have to be collated and then passed on to the doctor, who would then communicate the results to the patient. This means it would take much longer for the person to know if he was able to enter the centre or not, depending on how quickly he can get an appointment to see his doctor. Also, it would increase our administrative time as we would have to organize our communication through the doctor. Our budget is very limited and if we spend more time in administration, that leaves us less time to train volunteers to run communication programs.

Physicians are usually not knowledgeable with respect to communication problems. It is outside their scope of practice and training. Not only would this bill result in delays of service provision, increased administrative time and costs, but it would also mean the patient would not be given the best information by the person best trained to understand and explain the disorders.

Our members would also be directly inconvenienced by this. Most of them come in wheelchairs as a result of paralysis that accompanies the stroke. Increasing their visits to doctors to get speech-language pathology assessment results would involve more transportation costs, since most of them use Wheel-Trans. It would also mean an increased cost to the already overburdened health care system based on extra unnecessary visits to physicians.

However, our biggest concern about using a doctor to communicate speech-language pathology conclusions is that patients with aphasia will not understand what is being communicated to them. Research has shown that you have to use different strategies to communicate with aphasic individuals. They do not understand speech as they did before the stroke. It takes training and practice to learn how to communicate with them in a way they can understand what is being said to them. A speech-language pathologist has a background in this area while a doctor does not. I am concerned that our members might not be able to make informed decisions if the person discussing conclusions with them is not the one who did the assessment and is not someone who has received special training in how to communicate with aphasic individuals.


The second clause that concerns us is that this legislation only covers acts done in the course of providing health care. The legislation does not apply to settings outside health care. This seems to be allowing a form of false advertising where in one setting you can call yourself a speech-language pathologist but if you are in another setting, for example a school board, you are not regulated. We believe it would be confusing to consumers to control the use of certain titles in health care but then not control them in other settings. The service is the same independent of setting.

We wonder why the legislation does not protect the title "speech therapist." Some of our speech-language pathologists were originally trained in South Africa where their official title and the title appearing on their degree was "speech therapist." We also know that graduates of British schools use the title "speech therapist." Indeed, many places in Ontario still use the old title. We think it is important that consumers know that speech therapists and speech-language pathologists are the same people and therefore both titles should be protected.

Finally, I support the right of speech-language pathologists who have earned a PhD to call themselves "doctor," both without and within a medical setting. The restriction of use of the term to only one setting may be confusing to our aphasic clients and their families. Thank you very much for your time.

The Chair: Thank you very much. It was a very thoughtful presentation. It is good to see you again.

Mr Beer: It is good to get a very practical example in terms of where you are working and how you see this affecting the work you do. As you know, we have heard from many on this particular issue and particularly from speech-language pathologists. Is there a distinction in your mind here, when you are dealing with a patient in your centre, between diagnosis and assessment? I guess that is what we are struggling with. I do not think anybody is looking at stopping you doing what you are doing.

Miss Arato: Maybe I will pass it over to the speech pathologist.

Ms Kagan: Yes, there is certainly a distinction between assessment and diagnosis. What is of concern to us is that there is an unintentional aspect to this legislation in that the logical result of the assessment is to come to some diagnostic conclusion. To give you a practical example, if someone who has been on our waiting list comes in for a visit with an assessment of aphasia, and it appears to us from what we observe that things are not quite as they were on the original report and we redo an assessment, we would possibly then come to a conclusion that may differ in certain aspects from the original report we received. It might turn out that there is an apraxia, for example.

Mr Beer: Sorry, can I just stop you there? That report you received would have come from a doctor.

Ms Kagan: No, at the moment that report comes directly from a speech-language pathologist. So in our minds when we look at this legislation, what we would then have to do is not communicate that to the client who has now come into our centre, but we would have to go back to the doctor because this is now a diagnosis that is going to have some impact on whether the person is suitable to enter our program. Possibly the client or the patient would then have to go back to the doctor to be informed of what that diagnosis was. We would have to communicate with the doctor, the doctor then with the client and possibly then we would discuss what would happen. It just seems to be an unnecessary addition or layer, although as Pat pointed out our major concern is in another area. If I have a minute, I would not mind just elaborating on that.

Our centre has been running -- we are into our 12th year at the end of November. One thing we have learned, which I think is the most essential thing I have learned at our centre, is that speaking to people with aphasia, communicating with aphasic individuals is not something that comes naturally, either to the lay public or to professionals. We certainly know that, because family members, who are the most motivated and who are with the problem the most, are not expert communicators with their aphasic family members. This is a prime concern to us, that doctors, frequently by their own admission, are not trained in the techniques of getting information into the head of someone who is aphasic, and even more important, making sure they have an opportunity to let you know how they feel. We train volunteers. This is what we do every day. We know it is nothing to do with intelligence. We have volunteers coming from many professional backgrounds, including allied medical professions, who do not know how to do this. That is a major concern for us.

Mr Beer: If I could just follow up on that, because I want to be clear here on the way in which you are working with the doctor and then applying that to the new legislation, at your centre would everyone who comes there at some point in the process have been referred by a physician to the centre or to a speech language pathologist?

Ms Kagan: I could not say whether every person would have been referred by a physician. I would say in the majority of cases.

Mr Beer: The majority.

Ms Kagan: But it is not required for our centre that they be referred by a physician. It is just the practice that most people will have been referred.

Miss Arato: People can come from hospital, because they come straight from the hospital usually.

Mr Beer: But where that has happened, a medical diagnosis has been made by someone. After that having been done, then is what you are doing not in effect what I call the assessment? Even if you come to some different determination in the normal course of your practice, if that differed from what the hospital or a doctor had said, you would go back and say: "Look, I don't understand why you have said A, B and C. It seems to me we should be doing something else."

Ms Kagan: When you say go back and say we do not agree with what the doctor has said, it would be that we have not agreed with what the speech pathologist has said. The doctor will often refer to the speech pathologist but the fine diagnosis is often made by the speech pathologist. Just in terms of scope of practice and areas of expertise, aphasia is a very little understood disorder. Based on our experience, most family doctors really do not have much experience with this disorder.

What you will have if the person has come through a hospital access route is that he will have been seen by a neurologist. There might have been a diagnosis of aphasia, there might not have been. There has presumably been a referral to a speech pathologist. But our information will come from a speech pathologist, and that will include information from the doctor in terms of where the site of lesion is.

Mr Hope: I was just re-reading the beginning of your brief. You train volunteers to carry out communication programs. Then you go on with title protection, looking at school boards. I guess, using the same formula as you use, that you have people you train to do a job. They are doing it, because you are not directly with each one of them. Yet on the other hand you talk about school boards for title protection. I really do not understand the difference between what your volunteer workers do on the job with the communication program and what somebody may be doing who is in a school board setting.

Ms Kagan: Are you talking about the actual issue of protection of the title in the two different --

Mr Hope: You have brought the protection of the title to us, and at the same time I am looking at quality assurance, where you are having a speech-language pathologist training volunteers. There is a questionable quality assurance issue. Who is accountable? I would like to know that. The other part is that you talk about, on the school board level, using people who may be more inclined to know what is going on than your volunteers. I am having a hard time balancing out those two.


Ms Kagan: I do not know if this will answer your question or not, but our program is a very closely professionally supervised program so that, as I was explaining earlier, all members come in with a full assessment. They are assessed by speech pathologists. There is a lot of interviewing and pre- and post-assessment protocols that are followed. Our training of volunteers is also quite a rigorous, intensive one, closely supervised and closely monitored. It is not just for an economic reason. We have a certain philosophy of care which, if we have time, we could go into.

Speech pathologists form an integral part of their program. We are very aware of quality assurance issues, certainly in terms of things like evaluating the progress of clients who come in. We follow up. We look at changes in communication status as well as social status resulting from work that is being done by volunteers. It certainly is a professionally supervised program.

What I do not understand is that I think the title of "speech therapist" should be protected in any situation where you have a professional person working and where there could be a potential misunderstanding about who is qualified to do that work. Somebody who is not a professional speech language pathologist is not qualified to do what I do at the centre. This is not a job that can be done by a layperson. I do not know whether that answers what you have asked.

Mr Hope: The only thing I bring forward is the confusion to the consumer, the confusion to the people you are treating or helping with the communication program and the people who are doing the volunteer work. I am trying to get a grip, an understanding. You are using the confusion for the consumers with the title protection. Then you are using volunteer workers. I am wondering if the confusion is also there with your patients.

Ms Kagan: I am not sure whether or not this is the misunderstanding, but possibly what is happening here is that there are certain issues that are of direct concern to us at our centre, communicating diagnosis and one or two of the other issues. This is an area, I suppose, of more general concern. We are making our comments as someone who deals as a speech pathologist, of concern in a more general sense. But you are right, that does not apply specifically to our centre.

Miss Arato: That should be protected, that we are qualified to do that. Our volunteers are not qualified speech pathologists. They are trained by speech pathologists. They work within that setting.

Ms Kagan: Actually, there is something interesting out of your comments, in that I can think of particular instances where volunteers might have told someone else about what they were doing and called themselves speech therapists and had some pretty angry colleagues.

The Chair: Thank you very much. We appreciate your appearing before the committee today. If there is additional information that you think might be helpful, you can always write to us via the clerk.


The Chair: I would like to call now the Clarendon Foundation and ask that you introduce yourself for the committee, just for the purposes of Hansard.

Mr McInnes: My name is Ron McInnes. I am a member of the board of directors of the Clarendon Foundation and currently secretary of that organization. This committee has already heard from Vic Willi of the Centre for Independent Living in Toronto concerning independent living for people with physical disabilities and the importance of self-directed attendant services. I believe it has also heard from a representative of at least one organization which provides attendant services to adults with physical disabilities. Clarendon is another such organization and wishes to emphasize the importance of the concerns which have already been raised.

Clarendon is a non-profit corporation which provides attendant services to physically disabled adults in two support service living units, which are usually referred to as SSLUs, in the city of Toronto. The services which Clarendon provides are funded by the Ministry of Community and Social Services. They are provided to men and women living in their own apartments or co-op units, although Clarendon itself is not involved in the provision of housing.

The services of Clarendon's staff are provided on a 24-hour-a-day basis pursuant to a service contract between Clarendon and the consumer. The purpose of Clarendon is to provide the physical assistance required by the consumer to enable him to live independently, to go to school or work or participate in voluntary activities; in summary, to be active participants in the community and society.

I have attached the "Guiding Principles" and the "Mission Statement" of Clarendon to the copy of the presentation that has been distributed.

Clarendon was incorporated in 1974 and began operating one of the first projects in Ontario in 1975. Over the past 16 years, Clarendon has had to be constantly vigilant of escaping what I call the spectre of the medical model in the delivery of attendant services or attendant care, as it used to be known. We do not want to become an institution in the community.

In this context, we were very much concerned with one of the original recommendations of the Schwartz committee. Shortly after the report of that committee, we engaged in discussions with representatives of the Ministry of Health and the Ministry of Community and Social Services, at which time it became very clear that those responsible for drafting that report were not aware of the impact of the recommendations on agencies which supply attendant services to disabled persons.

The provision which caused that initial concern has been essentially carried through into Bill 43 in section 26. The controlled acts set out in paragraphs 5 and 6 of subsection 26(2) would encompass many of the routine tasks performed by attendants for disabled persons under the direction of those disabled persons and required solely because that person is unable to physically perform the act on his own. At Clarendon, we have never regarded such tasks as being health care services and our staff has been providing them regularly since 1975. However, since there is no definition of the term "health care services" in the bill, we must be concerned that our foundation and its employees may in the future be subject to the very serious penalties provided for in section 36 if these activities are not clearly and specifically exempted from the proposed legislation.

We presently have a situation in this province where a number of SSLUs and outreach programs, which provide similar services to disabled persons in their homes, feel they must refuse to provide certain types of assistance to disabled persons because they, or in many cases their insurers, feel the task is medical in nature and only to be performed by a health professional. Bowel evacuation and catheter procedures are the most obvious examples, but there are others.

Without a specific exemption, Bill 43 will only reinforce this misconception and thereby limit the independence of disabled persons by taking away their right to determine the extent and timing of the services they require and put severe restrictions on their lifestyles. It will also unnecessarily subordinate provision of these routine services to the control of a health professional. For organizations such as Clarendon, costs could very well become prohibitive, and the difficulties of scheduling services around the availability of a health professional would be insurmountable.

We are dealing here simply with routine living functions for persons with disabilities. Some of these differ from what is routine for persons without disabilities; others do not. However, the only difference of substance in our submission is that the person with the disability requires assistance from another person who acts at his request and under his direction. It must be made clear that this bill will not interfere with that relationship. The control of these services by the consumer is sufficient. External medical regulation would be both intrusive and inappropriate.

A commitment has been made to create an appropriate exemption through regulation. While it may be necessary to spell out some details by regulation, persons with disabilities and the agencies providing attendant services feel strongly that their primary concern must be addressed in the legislation itself.


Accordingly, the Clarendon Foundation would like to add its voice to those requesting that this committee recommend an amendment to Bill 43 to include an exemption for acts which might otherwise fall within the definition of "controlled acts," where they are performed in the course of providing physical assistance with routine activities of living to persons who are physically unable to perform them by themselves. The amendment should provide for an exemption to subsection 26(1), which would apply to acts otherwise falling within paragraph 5 or 6 of subsection 26(2); would apply to the routine activities of living of the individual requiring the assistance, and would relate to physical assistance provided at the request and under the direction of the consumer.

Thank you for your attention.

Mr Hope: Your concerns have been echoed a number of times, and I am sure the government itself and the previous government had no intention of making sure the disabled community would be a victim of the legislation dealing with attendant care. I know there were a number of conversations. Listening to you present your brief today, I understand you want it clear, without any interpretation for the hands of the interpreter. You want clear language put forward after the fights you have gone through all these years. You do not want to re-encounter that fight so you want clear, definite language about attendant care being exempted from the health regulations.

Mr McInnes: That is true, yes. The concern about leaving it for any regulation is that it would mean the control and the obvious restriction, which is there on a plain reading of the act, would be in existence and we would not know what the exemption might state or when it might come into effect. I think the people and the agencies affected by this are very much concerned at this stage. This is a very strong wish, as I am sure you have heard, and I do not think it is a difficult task to make this a very clear exemption within the act.

Mr Hope: Say, for instance, it was not part of the bill and went to regulations, do you feel there may be a battle for the disabled community that then would have to talk to the professions to make sure their concerns were in the regulations?

Mr McInnes: I think at this point there have been a number of discussions with the concerned health professions over this particular issue, and I think tomorrow you are going to be presented with some wording that has been worked out between those professionals and some of the agencies and individuals concerned. I do not think it is a difficult task, I do not think it was that difficult to arrive at this wording and I do not think it would be that difficult to put it into the act.

Mr Beer: It follows along there and presumably that wording would find its way into section 28, where the other exemptions to the controlled acts lie. Would you still see, with whatever wording came up, there would be a need for regulation as well, or some further interpretation? In your mind, is there a definition of the term "attendant services" that is sort of whole and complete within itself or would there still be a need for some more specifics with that?

Mr McInnes: In my mind, I would say there would not be a need for it. Others may disagree, of course. I depends on the wording of the exemption. The wording as I see it and as I think it will be presented to you will not make use of the words "attendant services" and therefore it will not be necessary to define it.

The Chair: Thank you very much for your presentation before the committee today. We appreciate your taking the time and I know you are aware that if there is additional information you think would be helpful to the committee, you can communicate with us in writing at any time.


The Chair: I call the Canadian Hearing Society. Welcome to the committee.

Mr Morrice: Thank you, Madam Chair. My name is Denis Morrice. I am the executive director of the Canadian Hearing Society. With me is Joan Beattie, a senior manager for the Canadian Hearing Society. She is really here to keep me on track and probably to answer a lot of the questions I will not be able to answer.

My first comment is thanks for the opportunity to present to the hearings, but I guess I want to say, where were you 15 years ago when we really needed it? So much has happened in the past 15 years. A lot of changes and a tremendous number of improvements have happened. We really needed it a long time ago. Services to deaf and hard-of-hearing people in Canada -- for all the MPPs here, just so you know -- are a disgrace. We have been in a continual state of transition in terms of hearing aids and testing for the past 15 years and I hope the legislation is able to look at the year 2020 in terms of what we really want for the future.

The Canadian Hearing Society provides services to deaf and hard-of-hearing people and we have provided the most comprehensive services in North America. We have doctors, audiologists, technicians and counsellors. I have always said we are the best consultants in the country, not because we can suggest to people what they should do, but because we have really tried it and have made a lot mistakes, so I think we can give a lot of input to people.

Our mission statement for members is that we are there to meet the needs of deaf and hard-of-hearing people as those needs are identified by deaf and hard-of-hearing people. I say that for the reason that the Canadian Hard of Hearing Association presented to you last week, I think, and because our mandate is to support the consumer groups. That is where our position would tend to lead us.

In 1986 Mr Alan Schwartz suggested we do more consultation with the various stakeholders, and to that end in 1986 we met with every single official professional organization and every consumer group, held open forums and attended every North American conference on hearing loss. What we were trying to do was glean from that suggestions and comments that could be made for the upcoming legislation, so I hope the comments I can make now will help. It is really based on all our communication and discussions with the various groups.

I would first like to put it into a bit of a historical context and I think it is only fair that all of this be put in a historical context. That is why my opening statement about the 15 years is pretty relevant. It was not that many years ago that European manufacturers dumped their hearing aids in Canada. They were hearing aids that did not meet manufacturers' specifications. That is simply because Canada did not have a standard for hearing aids. Also, manufacturers gave free trips. It is like, "Sell a couple of more hearing aids and you get the next trip to Sweden." With hearing aid dealers, any one of you could set up a business and start selling hearing aids. It was door-to-door salesmen, 30,000 flyers distributed in a community and then set up in a hotel room. It was really left to the reputable hearing aid dealers to carry on the service for those people.

Audiology is a very young profession. It was not many years ago that there was not a single audiologist in Canada. The Canadian Hearing Society hired one of the first audiologists. But along came this new profession when it was very clear what doctors were doing, what hearing aids were doing and what the role of audiologists was and then audiologists starting dispensing hearing aids, which caused a great confusion in the professional communities.


We then go on to doctors. Most GPs, in terms of their training -- I am sure you have heard it before -- receive little training on hearing loss. Most ear, nose and throat doctors are nose and throat. That is where the surgery is. It is not on the ears.

In terms of equipment, it was not many years ago -- we are talking about really archaic equipment compared to today. We are talking about probe tube mikes, etc. The level of sophistication has expanded tremendously. We were talking about a body aid not many years ago. Now we are talking about canal aids in the ear, behind the ear, FM systems, infrared systems and programmable hearing aids. That level of technology has advanced tremendously.

Along with that, during this transitional period, came the assistive devices program. ADP was the largest significant factor that created that level playing field -- a little bumpy, but certainly a level playing field for everyone -- and sorted out a lot of what was going on or what was wrong with the system. On top of that there was this Minister of Health in the previous government who created an Advisory Committee on Hearing Aid Services, which once again went beyond ADP to say: "Someone has to look at this. Someone has to take a damned good look at it. It's too complex."

We had another Minister of Health way back called Frank Miller. Mr Miller did what I think a lot of people do in trying to look at an area. He set up a task force to look at the roles and scopes of audiologists, audiometric technicians and hearing aid dealers, and a report was done and no one got to see the report. The reason no one got to see the report was because he realized it was so complex. But the Advisory Committee on Hearing Aid Services that was established involved all the stakeholders. They were able to stand back and take a good look at it and they are dealing with all the problems, a very difficult job, where every one of the stakeholders is there. They are dealing with the issues.

Today, in terms of the legislation and the act itself, I hope it is not looked at in terms of the specific regulations in isolation of this historical context and what is happening and all the good things that are now happening. The Canadian Hearing Society went into the hearing aid business a number of years ago, in the late 1970s, because of its concern. Within three years we were the largest single distributor in Canada. We went with a three-tier system to guarantee a professional service and to make sure the cost of hearing aids was the same right across this province. Our board of directors recently passed a policy that it supports the three-tier system and that it understands there will be exceptions, be it the rural communities, nursing homes or whatever and that they would have to be identified at some point. The Canadian Hearing Society services have been referred to by many people as a Cadillac kind of service.

I would now like to deal with a few points and one is access. When you look at some of the statistics, per 1,000 population in the urban areas, we are talking about 1.1 people getting service. In rural communities it is 0.3 per 1,000 people. There is an access problem. I do not care how you cut it, there is an access problem so there is a concern on that.

The other point I would like to make is on training. The Advisory Committee on Hearing Aid Services developed exams and administered those exams, but it was really for grandfathering of non-audiologist authorizers. I would just like to make the comment that should your committee decide to go further with that, beyond grandfathering, you should definitely look at a two-year official community college program if you are going to do that.

The third point is really dealing with risk of harm. It is really a difficult one in this field. The major focus has been on a hearing aid being too powerful and how that would be damaging. For an adult, one would say that a person can lose more hearing, that it causes headaches and that there is stress attached to it and so on, but one cannot help but think that as an adult one would simply turn it down. But for children there is no question that there is risk of harm. When a child is born with a hearing loss, language development is imperative and there should be ongoing monitoring with audiologists playing a major role. So there is certainly a risk of harm with children.

Now I would just like to deal very quickly with some of the points with the specific regulations. Then we may even have a longer break. Again, I would just like to bottom-line it by saying that the Canadian Hearing Society supports the consumer groups, but on that there is the protection of title. Before I go to protection of title, I am saying this with the full understanding that ADP and the Advisory Committee for Hearing Aid Services will stay in place, because that is the real protection.

On protection of title, we support the Ontario Association of Speech-Language Pathologists and Audiologists in terms of the protection of title for audiologists, speech pathologists and speech therapists in all settings, wherever they function.

Conveyance of a diagnosis has to be clarified, and I am sure you have heard it with every other profession. The concern clearly cutting through it is that audiologists and hearing instrument practitioners are concerned that they will not be able to convey the results of their tests to their patients. They are the people who are trained. Doctors are not trained to do that. I am sorry; they are just not trained to do it. On top of that, it is costly and very time-consuming. It certainly would not be in the best interests of the consumer.

However, in its definition of "diagnosis," if it is really an assessment that the professional can communicate, then fine, but those professionals, those audiologists and hearing instrument practitioners, must be able to convey what they have found in their results to their patients.

Prescription: This is more complicated now and it is because I did not really understand what you meant by "prescription." If it means that the profession would simply say, "Yes, you need a hearing aid," which is basically a generic kind of assessment, then we would support that doctors or audiologists would be the ones to do the generic kind of assessment. This is for the obvious medical reason: to make sure that nothing else could be done for that person. The person would then be seen by an audiologist or a non-audiologist authorizer for a hearing aid evaluation and a proper hearing aid selection.

Under that generic fitting, if that is what it means, we would also say that prescription should hold for the consumer so that he can go and get an extra aid, a backup. Many hard-of-hearing people want a backup hearing aid. Many people want a second hearing aid. Why should they have to go back through the whole system again? So we are saying that prescription should hold for them unless there has been a very significant change in their hearing loss, which may mean that something has gone wrong medically. That is if it means a generic assessment in terms of diagnosis.

If the prescription means a very specific type of aid, we are into a different ball game. Then, as far as I am concerned, doctors are not qualified to do that. It is very complex circuitry. The field is changing all the time and with all the doctor's other responsibilities, it is not fair to a doctor to load him with those kinds of expectations. So the right to prescribe should be given to audiologists and qualified non-audiologist authorizers.

Under that system, this would be with the understanding that there would be a doctor's medical examination. Under both those systems, no matter how you clarify the legislation, we must ensure that the consumer is protected, that the consumer is seen by two hearing health care professionals, and that there be no mutual financial benefit to these two professionals. That is as clear as I can get.

The Chair: We appreciate the excellent presentation before the committee.


Mr Martin: It was a good presentation and very encompassing. I do not know if you know or not, but Gary Malkowski, our colleague, is normally on this committee. He is not here now because he is on the select committee on Ontario in Confederation. I am trying to imagine what he would ask you in light of this legislation and in light of your role out there as an advocate on behalf of the group he belongs to. In terms of the deaf and hard-of-hearing, how would this legislation impact their ability to get what they need to participate fully in society?

Mr Morrice: For the deaf person it would be an interpreter. They would need an interpreter to see the doctor, to see the hearing instrument practitioner, to see the audiologist, or we would ask that those professionals be fluent in sign language. At the Canadian Hearing Society, many of our audiologists are fluent in sign language so that is where deaf people would tend to go. The issue for a deaf person would really be interpreting services. This month alone we turned down 400 assignments in Toronto alone of deaf people asking for an interpreter. That is the issue for deaf people.

Mr Martin: So we could put the best legislation possible in place, but if you did not have an interpreter for this deaf person to access it, you might as well be whistling in the wind. Is that what you are saying?

Mr Morrice: Yes. The issue in this legislation is really hard-of-hearing people. That is really the focus and that is what I think Gary would probably be saying, that this is really a hard-of-hearing issue as opposed to a deaf issue.

Mr Beer: I was interested in your comments about the assistive devices program and the advisory committee. I think you said at one point that however this legislation goes forward, it is critical that the program remain and that the committee remain. I just wondered if you could comment a bit on how you see that program and that committee fitting in with the new structure that would be set up, the council and so on, for the speech-language pathologists and audiologists, because clearly I think there would be a need for some kind of linkage there. How could they be supportive of each other?

Mr Morrice: I think ADP is, by default, governing all the regulations for the provision of hearing health care services and I think they have been doing a terrific job. In terms of the Advisory Committee on Hearing Aid Services, it has pulled all the stakeholders together, developed exams, and whether people like it or not, is forcing all those stakeholders to communicate. It is a complex field and this whole field is going to keep changing. This is not a static field. My goodness, something has to be there to keep these people moving together. They will come out with the policies and the regulations together.

Mr Beer: You see that council, the advisory committee, in effect having a more direct impact on all of those providers than, say, the council would have, because it would be more limited in terms of exactly who it was dealing with. So the protection of the public becomes critical for the work of the advisory committee.

Mr Morrice: Yes.

The Chair: Thank you for your presentation before the committee. We appreciate your coming forward today and I know you are aware that if there is additional information you think would be helpful to committee members, you can communicate it with us in writing via the clerk.


The Chair: I would like to call the Ontario Head Injury Association. Welcome.

Mr Roberts: Good afternoon, Madam Chairperson. My name is Bill Roberts. I am the senior manager of policy and development with the Ontario Head Injury Association. The Ontario Head Injury Association is a consumer organization that advocates on behalf of people who have sustained traumatic brain injuries and the people who live with those effects, which includes their family members.

The Ontario Head Injury Association therefore really looks at this legislation from the viewpoint of how it affects consumers. We do not set ourselves up as experts in the field of rehabilitation or as experts in terms of looking at the legalities of this new proposed legislation. However, our professional advisory committee was quite concerned when this new Regulated Health Professions Act had its first reading.

The Ontario Head Injury Association, through the members of its professional advisory committee, has reviewed the Regulated Health Professions Act. Through this group, we view the government of Ontario's intent to broaden the protection of the public as admirable. We applaud the proposed increase in appointment of public members to the advisory councils of the various professional colleges.

However, we are convinced that the proposed legislation contains some serious flaws, because the objectives will not be achieved through this proposal as it is written. We maintain that protection will be narrowed if this legislation is passed as presented.

The Health Professions Legislation Review, as you well know, undertook its work in 1982. In 1989 a final report was produced, with the purposes of the proposed legislation declared as to produce a better regulatory system for health professions in Ontario by giving governing bodies the power to regulate their professions more effectively and by making self-regulation of professions more accountable to the public and more open to public scrutiny, to provide better public protection and to respect the consumer's right to choose his or her health care provider from an array of safe alternatives, and finally, to permit more efficient and cost-effective delivery of health care services.

With respect to these objectives we have reviewed the proposed legislation and determined that there are numerous problems with the legislation. Specifically we have identified four major problem areas that will impact persons who live with the effects of traumatic brain injury. We list the problems below, then suggest potential solutions.

The first problem is that in the attempt to produce a better regulatory system for health professions, this legislation inadvertently could deregulate many professionals who practise in non-health care settings. In sections of the profession-specific acts which refer to the use of restricted titles, there is reference to providing "health care to individuals." This definition, we believe, is too narrow. Consider, for example, a speech-language pathologist who works for a school board. Under the proposed legislation this professional would be deregulated because his or her position would not provide "health care to individuals." Many similar instances can be presented for other professionals such as psychologists working in the fields of education, corrections, community and social services and industry.

For the individuals and families of our association, there are already too few trained regulated professionals in the health care field who demonstrate an understanding of the sequelae of traumatic brain injury. Encouraging the deregulation of professionals in these other human service areas would further exacerbate this situation.

The second problem we have with the legislation is that by only restricting the title of "speech-language pathologist" the legislation could have unintentional consequences. "Speech therapist" is used interchangeably with "speech-language pathologist." Protecting only "speech-language pathologist" and not "speech therapist" when the public uses these terms interchangeably would lead to confusion. The use by other persons of the term "speech therapist" would suggest to the public that they have the qualifications of a speech-language pathologist, when in fact they may have other qualifications.

The third point we have problems with is that the holding-out provisions of the various professional acts are too narrow in definition. Unqualified individuals may infer that they have qualifications which they do not possess. One such example is the term "psychologist," which could be compromised by a title such as "counsellor in psychological services" or some other misleading description. In this situation the consumer would not be able to differentiate who was in fact a qualified member of the professional college. The public needs to be protected from people using descriptive terms which lead to confusion in determining who has received training and is a member of the appropriate professional college.

The fourth area with which we have a problem is that although this proposed legislation attempts to protect consumers' rights to select safe alternatives of health care, the legislation, as it is written, has unnecessarily created an inefficient system through the controlled acts section, paragraph 26(2)1. This paragraph states: "Communicating to the individual or his or her 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 representative will rely on the conclusion."

This paragraph creates the likelihood that a professional such as a speech pathologist, speech therapist, occupational therapist or physiotherapist who carries out an assessment and analysis will be unable to share this information directly with the patient. Not only is the time delay assumed by waiting for a doctor or psychologist to share this information unacceptable, but the cost incurred through double billing to the health care system is unnecessary. We perceive this proposed arrangement to be a new barrier to receiving effective and efficient health care for persons with traumatic brain injury.

Our proposed solutions to the problems are as follows:

1. We suggest that the phrase "health care to individuals" be replaced with "professional services to individuals" in the profession-specific acts or that the reference to "health care" be deleted. This revised phrase would not exclude qualified professionals in other human service areas such as education and community and social services or industrial settings under the legislation. For the above-noted reasons, we believe the consumer will be better protected.

2. We suggest that the title "speech therapist" as a restricted title be included in Bill 44, the Audiology and Speech-Language Pathology Act.


3. We suggest that to resolve the narrow definition of the holding-out provisions, the various professional acts be amended to read:

"No person other than a member may take or use any name, title, description, variation or abbreviation in any other language implying or calculated to lead people to infer that the person is qualified or recognized by law as a member of the college of" -- the appropriate college.

4. We suggest that the controlled act of diagnosis as written in subsection 26(2) of Bill 43 be revised to ensure that professionals such as speech-language pathologists, speech therapists, occupational therapists and physiotherapists can communicate their findings directly to their patients.

That is our very brief presentation.

The Chair: We appreciate your excellent presentation.

Mr Hope: First of all, thank you for making the presentation. I know your organization works for a lot of people, because I have had the opportunity of working with yours quite a bit.

When you brought forward the title issue, do you see a lot of problems with the current way the legislation is proposing? Do a lot of people say they have been misled, especially when you are dealing with people with severe brain injury who may be left out in the cold and not sure so they are grasping at whatever?

Mr Roberts: Yes, I think that is probably accurate. Certainly people with serious cognitive problems can be very easily misled, and I think that, for instance, there are individuals sometimes who are seeking psychological services, particularly neuropsychological services, and are quite susceptible to being very easily misled by someone who is using a descriptor. Someone who calls himself a counsellor in psychological services could be quite misleading to a person with a brain injury, and certainly to a family that is in a great level of distress, and that seems to characterize most of the families we deal with. They are often just looking for any kind of solution to a problem and it would be very easy for some person to describe himself or herself as having qualifications and extracting a fee when in fact he or she could not provide much assistance at all.

Mr Hope: Dealing with your first proposal about the professional services to an individual instead of health care, could you just elaborate a little more? You had me confused on that, especially when we deal with the social worker aspect of things.

Mr Roberts: I guess what we are trying to get at here is that in the very narrow definition of "health care" there are so many services that are being provided to people with traumatic brain injury in other kinds of settings, such as education. Unfortunately, some of our membership end up in the Correctional Services system and so forth, and by really just trying to focus on health care and trying to define health care, we think that could create a whole kind of conundrum for people trying to access service in other kinds of settings. There could unwittingly then be people who are providing services without proper qualifications because they are not covered under this legislation.

Mr Hope: Your proposals reflect your clientele because they may end up in the correctional facilities or through the Ministry of Community and Social Services, so you are mainly focusing on putting this wording on your own clientele that you deal with in making sure protection is there for them.

Mr Roberts: We are interested in changing the reading of the act to delete that notion of it just being in the health care services provided in the health care field. Is that clear?

Mr Beer: One issue you do not refer to here, and I just want to make sure what the position of the association is on it, is the point that was made previously this afternoon around attendant services and the concerns that have been expressed by a number that there be an exemption for those services to be provided by an attendant care person. Can I assume that your organization would want to see something such as that for attendant care workers?

Mr Roberts: Actually, that did not come up in any of our discussions, so it would be unfair for me to comment on that. The position I have here comes from the committee. Otherwise, it would just be a personal opinion, so rather than comment on that, I will just --

Mr Beer: Sure. That is fine.

The Chair: Thank you for appearing before the committee today. We appreciate your presentation, and I know you are aware that you can submit any additional information in writing to the committee at any time during our deliberations.


The Chair: I would like to call next the Ontario Association of Dispensing Opticians. Welcome.

Miss Raymond: Thank you for allowing me the opportunity to speak with you this afternoon. My name is Pat Raymond. I am past president of the Ontario Association of Dispensing Opticians. Currently I am still with the association in the capacity of vice-president and director of legislation. I have been working from the review stage through the current proposed act for the past four years.

Having studied the Regulated Health Professions Act in great detail, the Ontario Association of Dispensing Opticians, with the consensus of the Ontario Contact Lens Association and the Board of Opthalmic Dispensers, Ontario, would like to discuss with you the need to include a definition of "dispensing" as it applies to subnormal vision devices, contact lenses and eyeglasses. In addition, if time permits, we would like to express our concern with the delegation of controlled acts and possibly some of the authorized acts, but in particular our concern is with the omission of a definition of "dispensing."

The Ontario Association of Dispensing Opticians is proud of the quality of eye care currently attainable in this province. This is due in part to the high quality of standards placed upon the education of opticians and in part to the fact that within our current regulations under the Health Disciplines Act there exists a concise definition of "dispensing." With this definition, our regulating body, the Board of Ophthalmic Dispensers, has been able to successfully charge and prosecute non-members of this profession who engage in ophthalmic dispensing.

We urge you to consider seriously including a definition of "dispensing" in the new Regulated Health Professions Act, 1991.

For the purpose of section 4 and subsections 26(2) and 26(9), the Ontario Association of Dispensing Opticians, the Ontario Contact Lens Association and the Board of Opthalmic Dispensers, Ontario, agree that the following definition of dispensing is necessary for the administration and enforcement of the Regulated Health Professions Act and the accompanying Opticianry Act.

"Dispensing means:

"(a) interpreting a prescription for;

"(b) evaluating or advising a person in respect of; or

"(c) preparing, providing, verifying, adapting, fitting or duplicating a device for subnormal vision, a contact lens or eyeglasses."

According to the New Lexicon Webster's Dictionary, there is a simple definition of "dispense," which is to distribute or to hand out. This application's result would be that all interpretations and evaluations, measurements and lens designs, fittings and adaptations required prior to the final handing out of the appliance could be performed by an unregulated person.

Many considerations and variables must be taken into account before a prescription can be effective. To simply manufacture an appliance and ensure that it meets the parameters of the written prescription would be a disservice to the patient and for that matter to the prescribers.

For example, in our definition we are requesting the word "interpretation." To effectively interpret a prescription, an optician must consider the following aspects:

First, the power of the lens: In many cases the optician must compensate the written power of a prescription to effectively satisfy its requirements. For example, as a lens is moved away from or closer to the eye, the power of the lens is effectively altered. The optician can calculate for differences in lens placement in relation to the actual refraction distance. With this information, we can determine the power needed to effectively produce the power prescribed.

To make that simple, everybody here looks like he had a pretty normal childhood, and I do not think there is anybody here who has not tried to burn an ant hole or a piece of tissue with a magnifying glass, or at least watched somebody do it. The whole idea of taking the magnifying glass is to collect bundles of light and bring them to a point focus on that piece of tissue or leaf or ant hill and try to start a fire. If you can recall, if you were one of those kids who did it, and I am sure you are, you would bring the light to a point focus. There was a certain point where the light would become very sharp. If you held it there long enough, you would get a flame. If you took that magnifying glass and brought it a little closer to the object or a little farther away from the object, that point of focus dispersed and you could stand there all day and not get a little bit of a flame.


Eyeglasses work on much the same principle. We are gathering bundles of light to pass through the lens to bend that light so that the ray will fall right at the retina. If we move those lenses away from or closer to the eye, we are effectively changing where that point of focus will be, just like the magnifying glass.

An optician is trained to take that into consideration, to take the prescription where the doctor's instruments have made it a certain distance from the eye. If the new glasses are going to fit farther or closer than that distance, we can calculate a power of lens to order different from the prescription but which effectively gives us the same power as it relates to the distance from the face. That is one of the reasons we need this interpretation and this definition put into our particular act.

The frame position will also make a difference, like varying the distance the lens sits from the eye. Changing the angle at which it is placed in front of the eye, or the pantoscopic tilt, will also affect the power of the lens. This will cause an aberration in sight which is known as oblique or marginal astigmatism. If, to ensure a comfortable fit, we must change the angle of the glasses, we in effect are changing the effect of the prescription. Again, we must compensate and calculate a power that will effectively give us what the doctor has written on the prescription. Left uncompensated, both of these examples would result in reduced acuity, distortion, eye strain, headache, nausea, lack of depth perception and in some instances double vision.

Another concern we have to take into account before a lens is even ordered is the base curve of the lens the patient was wearing previously. The base or the initial curve of the spectacle lens determines the amount of magnification that will be induced by the lens, separate from the prescription. A single power or a single prescription is available in several different base curves. To just arbitrarily supply lenses without taking this into consideration can result in adaptive difficulties, such as loss of depth perception, reduced eye-hand co-ordination and headaches.

In the second part of our definition, we request the wording "prepare and provide." Once the prescription has been interpreted, measurements are taken to accurately design and prepare an appliance. The placement of the eye, for example, must be measured both horizontally and vertically within the parameters of the lens opening of the frame. It is imperative that the optical centre of the lens -- this is where the light ray travels at the straightest line -- will align exactly with the point where light enters the eye. To deviate from this point at all, we get what is called a prism effect, which again can result in double vision and disorientation. I have included a list of some of the measurements that we do take in fitting eyeglasses and contact lenses. I will not read them now.

We would also like to see "duplication" included in our definition. The duplication of a pair of glasses or contact lenses is not merely the copy of the dioptric power, that is, the lenses, given to us. Even if only one lens is being replaced on a pair of glasses, we have to take into consideration the base curve of the original lens, the optical centre placement and the decentration so as not to induce uneven magnification between the two eyes, so we will not have one image coming bigger than the other, which again will cause a double vision or imbalance. This will also cause a prism effect. We have to watch for all of these things.

In the case of contact lenses, the fitter would be terribly remiss not to assess the current lenses and take new measurements. Corneal changes, as well as other factors, would result in the necessity to redesign the lens. Not to do so would put the patient at risk. Even minor adjustments necessary to the design, left uncorrected, can result in corneal ulceration, vascularization or corneal infection.

The final verification, that the prepared appliance meets all the criteria of the design ordered, that it is carefully conformed and modified to satisfy the intent of the prescription and is fit comfortably on the patient, requires the expertise of a trained professional. An improper adaptation or fitting of a pair of eyeglasses would undo all the careful steps taken by the optician to measure, design and prepare the appliance. A poorly adjusted frame, in addition to the more obvious physical discomfort, can cause visual anomalies due to incorrect angling, nose pad adjustment or slippage resulting from improperly adjusted temples. Even marginally incorrect fitting or adapting of a contact lens would result in aberrations and ulcerations leading to infections, and all leading to possible loss of sight.

From these examples, which list only a fraction of the information and background knowledge necessary to competently dispense a prescription for subnormal vision devices -- contact lenses or eyeglasses -- you can appreciate that there is considerably more involved in the dispensing of an optical appliance than the mere handing out of the completed product.

The members of the Ontario Association of Dispensing Opticians do not believe it is the intent of the Ministry of Health to indicate that these imperative steps of dispensing be unregulated, and we urge you to include a definition. Without a defined outline of the parameters of dispensing as it applies to this profession, the College of Opticians of Ontario, currently known as the Board of Ophthalmic Dispensers, Ontario, will be unable to effectively enforce the regulations or prosecute non-members for the protection of the public.

As this committee may already be aware, opticianry is a highly retail health profession, greatly influenced by large corporations. Within the Health Disciplines Act and the accompanying Opthalmic Dispensers Act, there currently exists a definition of "dispensing." With this definition, both the optician and the corporation are clearly aware of the boundaries surrounding the regulations affecting ophthalmic dispensing. With this definition, the licensing body has been able to effectively regulate the profession and successfully prosecute those who illegally step within its bounds.

As can be expected, a provincial court judge must rely heavily upon the wording of the law and how it applies to the charge. Using our current definitions, the board has been capable of bringing charges against those companies and individuals who have practised opticianry without respect of regulation or law. Also using this definition, the board has been successful in relating the charge to the definition, thus allowing the judge to fully understand the infraction. Might I add also that the board has seen a 100% success rate in convictions for every case brought before the courts.

We at the association do not believe this could be possible without a definition of "dispensing." A judge, not knowing the intricacies of the profession, would rely heavily upon the known definition of "dispensing" -- to distribute or to hand out -- should no other exist. Without a prescribed definition, large companies, which already dominate the industry, will reduce their regulated staff and keep opticians to a minimum, for the sole purpose of the final distribution of the product, and replace them with lower-paid unregulated persons. This is already evident. It is being tried in the province. That is why the Board of Ophthalmic Dispensers, Ontario, spends so much time in court. Without a definition, court time would be useless.

It is our fear that with no definition to rely upon, the regulating body will no longer be successful in its enforcement of our regulations and that the calibre of care currently achieved will be reduced to a commodity, with little or no concern for visual quality. So that is our greatest concern at this point, that a definition be added to the act.

If I have time, I would like to very quickly mention "delegation of controlled act." We are quite concerned with the wording of section 27, which states:

"(1) The delegation of a controlled act by a member must be in accordance with the regulations under the health profession act governing the member's profession."

"(2) The delegation of a controlled act to a member must be in accordance with the regulations under the health profession act governing the member's profession."


As much as we are aware that those issues are going to be covered during the regulation-making process, we feel it is noteworthy now. We feel that subsection 27(1) leaves too broad an opening for unqualified persons engaging in controlled acts. The implications of delegation to unregistered persons are already surfacing within the optical industry. In recent years there has been an increase in medical practitioners refracting. With little or no practical optics or dispensing experience, the delegation of spectacle dispensing has been given to unregulated assistants. For the reasons specified in our request for a definition of "dispensing," many of these patients are being fitted with glasses with little or no emphasis placed on interpretation, evaluation, design or adaptation.

I was unfortunate enough, I guess, to recently have a patient referred to me by an ophthalmologist. She had been examined by a medical practitioner and a prescription was given to her for eyeglasses. She was in turn sent next door to the consultant to have eyeglasses made. After picking up her new glasses, she experienced extreme peripheral distortion, reduced field of vision, lack of depth perception and severe headaches. She returned to the optical dispensary and discussed her problems with the consultant, who, by the way, the patient erroneously assumed was an optician. She took for granted this was an optician.

Not having had any training or education in physics or practical optics, the consultant was limited in her ability to troubleshoot the situation. She determined that the lenses had been made correctly to the doctor's prescription, could find nothing wrong and sent the patient back to the doctor. The doctor re-examined her and said: "No, that's the prescription I want. That's the prescription you got. You'll be fine." She went back to the consultant, who told her: "Give it a little time. You have to get used to the new prescription."

Two weeks later she was back at the dispensary. Her headaches were worse but the distortion had gone down a little bit. The assistant again said, "Look, the glasses are right. That's what the doctor ordered." To make a long story short, they sent her to her family physician because they told her it had to be a physical problem. By the time she got to a doctor, she was sure that she was dying, that she had a brain tumour. The doctor could find nothing wrong and sent her to an ophthalmologist, who could also find nothing wrong.

It turned out that it was simply a lack of interpretation for the prescription to the appliance. We made her new glasses in the identical prescription and she is fine today, but she went through hell for almost a month and a half.

There are two very important issues derived from that case scenario. One, the unfortunate individual could have been saved a great deal of physical, mental and visual anguish if she had been fitted by someone who was trained in the art of opticianry. Second, visits to three doctors, two of them more than once, and a host of lab tests were all billed to the Ontario health plan, all needlessly and all at the expense of the Ontario taxpayer.

I will be quiet now.

Mr Beer: If I might, a question to the parliamentary assistant: In the brief it is noted that the Health Disciplines Act and the Ophthalmic Dispensers Act contain a definition of "dispensing." I was wondering if it was considered to place that as well within section 26, and if there was a reason why that was not done.

Mr Wessenger: I will ask counsel to reply to that.

Ms Bohnen: The review was asked to place a definition that would more or less be the same as the current definition in the Ophthalmic Dispensers Act into the new legislation, and thought it inappropriate to do so. You might want to explore that more fully with Mr Schwartz.

Mr Beer: I wanted to just be clear that this had been put forward but the review had decided not to do that.

Ms Bohnen: Yes.

Mr Beer: We can go over that and go over these arguments when we have his testimony.

The Chair: Thank you very much for appearing before the committee today. We appreciate you taking the time. If there is any additional information you think would be helpful to the committee, please feel free to submit it to us in writing via the clerk.


The Chair: I would like to call now the Board of Directors of Chiropractic. Welcome to the standing committee on social development.

Dr Burge: Good afternoon, Madam Chair, members of the committee and guests. I would like to thank you for the opportunity to present the views of the Board of Directors of Chiropractic on one of this province's most significant pieces of health care legislation ever. My name is Ted Burge, chairman of the board. With me are Mrs Sylvia Pusey, a public member of the board, and Dr Stan Stolarski, the registrar.

The members of the Board of Directors of Chiropractic are appointed by the Lieutenant Governor. The board is the regulatory body for the profession and has responsibilities in four main areas: prescribing of examinations for the admission of chiropractors to practise in Ontario, registration of those meeting the criteria outlined in the Drugless Practitioners Act, discipline of chiropractors under the same act, and regulation of the profession.

The past eight years have been an exciting and busy period for the board. We have been active participants since the beginning of the Schwartz review. At this time we would like to commend all those who participated in the process since Mr Schwartz made his initial recommendations. I would like to pay a special tribute to Mr Alan Burrows and Ms Linda Bohnen, who have been wonderful people to work with.

Mr Owens: Let the record show applause.

Dr Burge: The support of three governments for this legislation indicates its importance, and I have no doubt that since the hearings began you have heard many others make positive comments about the proposals.

At the outset, I would like to reiterate that the Board of Directors of Chiropractic is supportive of this legislation. We applaud its goals of public protection and freedom of choice in health care. However, as I am sure you have heard from other submissions, our profession has a concern with the legislation in its current form. We would like to focus on the issue that we consider to be of primary importance to the patients of chiropractors.

We all understand that the Regulated Health Professions Act should to the fullest extent possible protect the public from risk of harm from health care providers and ensure that each citizen may exercise a freedom of choice within a range of safe options.

The board would like to draw to the attention of the committee that the proposed scope of practice contained in the Chiropractic Act includes the treatment of articulations of the spine and non-spinal articulations. The proposals also provide the statutory authority for diagnosis by a chiropractor of dysfunctions or disorders arising from the structures or functions of the spine and their effects on the nervous system. Our board believes this provides significant statutory protection for the patient with respect to diagnosis and treatment of the spine.

However, there is something missing from this scope of practice. I refer to the statutory authorization for the diagnosis of articulations other than those of the spine. This is a specific area of chiropractic expertise, but if the proposals are implemented as is, it will disallow the patients of chiropractors to be informed of a diagnosis of articulations other than those of the spine.

A diagnosis, not an assessment, is demanded by many insurers, employers and third-party interests. The lack of authority for a chiropractor to diagnose these problems will result in added costs to the health care system and will restrict an individual's freedom of choice.

Notwithstanding chiropractic inclusion in workers' compensation, OHIP, veterans' insurance, no-fault insurance and major medical coverage by private and group insurers, it is still a common occurrence for employers, insurance companies, lawyers, and in general third-party stakeholders, including other health professionals, to interfere with the freedom of patients to seek chiropractic care.

Permit me to give you some examples which apply to personal injury, liability and disability claims or, for that matter, any claim by a patient that has to go through a process of adjudication:

1. Chiropractic patients are often required to obtain confirmation of the appropriateness of their chiropractic care from a physician;

2. Legitimate claims by patients for disability compensation are often challenged by the insurer, and chiropractic patients are forced to validate the opinion and care of their health care provider through consultation with a physician;

3. Employees are sometimes directed by their employer to seek other resources for health care and in some instances are directed to discontinue care with their chiropractor.

Many patients are intimidated by fear of reprisal from their employer or the Workers' Compensation Board, and in many instances are just uncertain that their claim will be reimbursed. Despite reassurances, many patients are confused by these demands and forfeit a freedom of choice which in my view is a hallmark of the legislation we are addressing today.

These patient problems centre around the lack of authority of a chiropractor to state on behalf of the patient a conclusion identifying the etiology of the patient's condition. If the authority were recognized, chiropractic patients would enjoy the advantages.


In these circumstances, the chiropractor and the patient are frustrated. The patient is helpless as a wedge is driven between the chiropractor's responsibility to his or her patient and the patient's need for treatment, and inevitably the patient is the victim.

There is an appendix -- although I must add that it is quoted just below this paragraph -- attached to this brief, issued by the superintendent of insurance in Ontario. Although this bulletin is slightly dated, nevertheless the concerns are as current and relevant today as they were at the beginning of the review process. In our view, this memo speaks to the seriousness of this problem.

"Because of complaints received, I believe it would be appropriate to review some of the features of this coverage and, in particular, how they relate to chiropractors.... Reasonable and necessary chiropractic expense is covered. There is no requirement that such treatment be prescribed by a medical doctor.... Provided the claim for chiropractic expense meets the `reasonable and necessary' standard, I would look with disfavour upon any insurer who relies upon these parts merely to frustrate the claimant who sought out such treatment independent of medical consultation."

In practical terms, unjust demands by third party interests under the present system take licence to avoid payment of legitimate patient claims. The system takes advantage of the weakness and the current statutes provide no defence for a member of the public who wishes to exercise the freedom to choose a chiropractor for care when third-party payers wish to exert their power to demand other consultation or withhold payments.

Our board views the absence of statutory authority to protect the patient's right to a diagnosis of these problems by a chiropractor as the root cause. Should the freedom to access the health provider of choice include the risk of finding oneself in a helpless position to defend that choice? We think not.

The Board of Directors of Chiropractic, the Ontario Chiropractic Association and the Canadian Memorial Chiropractic College have suggested an amendment to paragraph 1 of section 4 of the Chiropractic Act which will provide a foundation for the eventual resolution of this problem.

We suggest an amendment that would provide for "the diagnosis of non-spinal articulations." While this amendment is important to the profession if it is to meet the expectations of patients, it is far more important to those members of the public who choose chiropractic care for problems not related to the spine.

In a survey undertaken by the Board of Directors of Chiropractic last August, the public expressed support for chiropractic as a trusted health care provider. The survey showed that 52% of respondents indicated that they or a member of their family have visited a chiropractor some time in the past. I will add that over 40% of those respondents had direct contact with a chiropractor.

Seventy-two percent of respondents who went to a chiropractor said they were satisfied and 47% said they were very satisfied; 73% believe that in addition to back and spinal problems, chiropractors are also appropriate for problems of the extremities, such as shoulders and knees.

The results of the survey confirm our belief that the public must be provided with a statutory safeguard against the persistent impediment to their access to chiropractic care and third party funding.

Chiropractors are well educated in diagnosis and treatment of articulations of the body, with over 600 hours of curriculum devoted to diagnosis and treatment of articulations other than those of the spine. This is a distinctive aspect of chiropractic practice and is understood by the public to be an option for those who may choose it.

If the proposals are not amended, only one profession of 24 will be authorized to diagnose dysfunctions or disorders arising from the structures or functions of articulations other than those of the spine. If this be the case, the public has no choice. The board views this as a flaw in the proposals. Perhaps this may be understandable if there were only one profession to perform this authorized act, but this is not the case.

We believe that if the proposal remains as it now stands, it will simply maintain the existing barriers to citizens who choose chiropractic care, and we therefore urge your committee to amend paragraph 1 of section 4 to provide for "the diagnosis of non-spinal articulations." I shall be pleased to respond to any questions.

Mr Owens: I do not have a problem in principle with what you are requesting. I do not quite understand, and I ask the parliamentary assistant to chime in and add clarification, why that element, the diagnosis of extremities, was left out. Your profession seems to be doing it with sports injuries. It seems to be doing it in private practice. So why was it left out?

The Chair: Mr Wessenger, you are requested to please chime in.

Mr Wessenger: Yes, I will ask staff to indicate the position of the review.

Ms Bohnen: As we have talked about before, the review's opinion was that the scope of practice recommended for chiropractors was what was appropriate and consistent with the primary function of chiropracters. Also remember that this does not restrict the treatments provided or the assessment capability provided by chiropracters. The only issue before the committee that is being discussed today is diagnoses of disorders and dysfunctions of non-spinal articulations. The issue, as it is being presented to you today, seems to be that chiropractors currently have some difficulty in this area with interference with patients' rights. Of course the legislation is not yet enforced, so you might be interested to explore what is the source of the current problem even before we have legislation, and can legislation reasonably solve this problem?

Mr Beer: This is partly along the same lines, but I wanted to be clear on the current situation with respect to non-spinal articulations. Is there anything that prevents you from doing that today, other than -- do I assume some companies do not accept the fact you do that? That was sort of the point of the first section, but in day-to-day practice, chiropracters are doing this. Is it partially accepted? Could you maybe explain how that functions?

Dr Burge: The issue is that chiropracters have always treated articulations other than those of the spine, and do to this day. I think the issue I am trying to emphasize today is that an insuring company will look to an authority to confirm the patient's disability or claim, and oft-times, it is my opinion and I think it is the experience of the profession, there is a way to work with this thing that allows the companies, in some cases, to avoid payment of claims. We are talking, in some situations, of where it really prejudices the patient's physician.

If someone has been off work for three or four weeks, anticipating a certificate of disability from a chiropractor, and then the insuring company does not accept it because it says, "Where is your authority to make that statement?" I am suggesting that if that is the problem, this legislation should address it. It should give the authority where the patient needs it and the authority is not in the patient's physician's office when the patient has been in the chiropractor's office for three or four weeks being treated. The authority should be with the individual dealing with the patient.

Mr Beer: Under the legislation as it exists today and regulations, is it that this is not clear, or is there a specific clause that says you cannot do this or you should not?

Dr Burge: No. I stand to be corrected, but I am not aware of any specific prohibition against the chiropractor making that authority. But I am equally not aware of a clear-cut authority defined in the Drugless Practitioners Act that says you can.

Mr Beer: As was said by counsel, as presently worded it would not prevent you from doing non-spinal articulations but it would prevent you from diagnosing?

Dr Burge: Absolutely.

Mr Jackson: I appreciate this brief, which is one of several we have received from chiropractic. In this one you talk about third-party interference, which is a very polite way of referring to the compromising effect of this legislative initiative for patients in a variety of circumstances. This is the one that concerns me the most, because, as counsel has made clear, we are dealing with a very narrow range of factors in developing this legislation. We are not really looking at the consequences of the relationship between the patient and some patients' rights issues or access issues. I understand that, but we are clearly going to be causing these kinds of activities to occur as a result of this legislation.

We have received persistent and consistent deputation to the effect that this would seriously affect the help that people are seeking and obtaining very successfully from chiropractors. Do you have any further information with respect to the WCB, or the recent changes in auto insurance from the previous government, or any cases of complaints that illustrate more clearly the concerns you have raised under the referenced third-party interference? I am familiar as a patient. It happened to me. My physician would not recommend it. I went to the chiro on my own and I received my treatment. Are you receiving --


Mr Jackson: It is a well-known case, former Madam Minister. It is the case of my wrist, since you wanted to hear all about it.


Dr Burge: I think I heard about that.

The Chair: I think it is all on the record, Mr Jackson. We can dispense with more description. I was just being rather cute.

Mr Jackson: I appreciate your raising the specifics of my wrist, but back to the point.


The Chair: Order. I will ensure that the time is added.

Mr Jackson: I have stated my question. Are there any other specific cases that have come to your attention? You are being a little polite here.

Dr Burge: I understand that. You must understand that the mandate we are representing is that of the public interest, but our board does not specifically deal with complaints about the Workers' Compensation Board. I would think, in response to your question, that the best answer I would give you is that I think we should probably sit down along with the association, which does have direct dealings with the Workers' Compensation Board and is more familiar with its function as an organization than our board is. We would be happy to make a submission that would give you further documentation on this if you wish, Mr Jackson.

Mr Jackson: Would you get that before the 16th, when we are meeting with various ministries in our opportunity to raise specific questions about the impact on WCB protocol? It would be helpful to us.

Dr Burge: I would be more than happy to see that is provided.

Mr Hope: This is around the same thing Mr Jackson had, other than that I did not hurt my wrist. I would like to look at the issue of the third party that you are talking about. A lot of the insurance companies are setting up, for instance, with the Workers' Compensation Board. I do not want to throw partisan stuff into this, but the board has its own doctors and still will not give you the right, even though we give you the right here. You still do not have that entitlement because there is still another body over here that has to approve of it. Even though we do consider what you are proposing today, it is still not going to allow you the access to the third party issue of insurance.

Dr Burge: I think we have to look at this whole process we have been through from HPLR to the present and understand that there is a whole change in the system. I think this legislation provides a foundation for everything that is going to happen from here on. Even to the point, I have been given to understand, that amendments and opening of other pieces of legislation with respect to health care are being more or less, if I can use the terminology, put on hold until this is in place. Once it is established that the scope of practice of a chiropractor is that, then as other acts are opened or as other pieces of legislation are dealt with, I would assume a lot of it would be predicated on what has been the established fact in terms of what a defined scope of practice for a profession is. In that sense, I think this is a stepping stone. I would not mean to suggest that this one approach is going to settle 100% of the problems, but it is certainly a foundation stone to settle on. It is part of the process.

Mr Hope: That is what I was going to say. It is just a foundation to maybe open up other avenues, because as we refer to workers' compensation and no-fault auto insurance, you still have another mechanism that you have to go through.

Dr Burge: I understand.

Mr Hope: Even though we can approve it here, it still will not help.

Dr Burge: I am suggesting I think it would be a very big help to us.

The Chair: Thank you very much for your presentation. The committee will look forward to receiving the documentation that you have said you can provide for us. You can do so just by submitting it to the clerk in writing. We will look forward to that. Similarly, if there is any additional information that you think would be helpful, we would appreciate receiving that as well over the course of our deliberations.

Dr Burge: Madam Chair, if I may, I have a letter signed by the Board of Directors of Chiropractic, the Canadian Chiropractic Association and the Canadian Memorial Chiropractic College proposing these amendments that I mentioned in the brief today. I would like to present that to the clerk.

The Chair: That is fine. If you will submit that, it will become part of the public record. The committee appreciates your advice as well as your submission today.

The committee adjourned at 1614.