ASSOCIATION OF SOCIAL WORK DIRECTORS OF THE HOSPITAL COUNCIL OF METROPOLITAN TORONTO
COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO
TASK FORCE ON SEXUAL ABUSE OF PATIENTS
COLLEGE OF OPTOMETRISTS OF ONTARIO
ASSOCIATION OF CHIEF PSYCHOLOGISTS OF ONTARIO SCHOOL BOARDS
COMMITTEE FOR INDEPENDENCE IN LIVING AND BREATHING
ONTARIO FEDERATION OF COMMUNITY MENTAL HEALTH AND ADDICTION PROGRAMS
LABOURERS LOCAL 183 MEMBERS' BENEFIT FUND
CANADIAN SOCIETY FOR ENVIRONMENTAL MEDICINE
COLON THERAPISTS ASSOCIATION OF ONTARIO
ATTENDANT CARE ACTION COALITION PLUS
KAREN KAHANSKY
STEFAN FRIDRIKSSON
CONTENTS
Wednesday 28 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
Association of Social Work Directors of the Hospital Council of Metropolitan Toronto
College of Physicians and Surgeons of Ontario
Task Force on Sexual Abuse of Patients
College of Optometrists of Ontario
Association of Chief Psychologists of Ontario School Boards
Committee for Independence in Living and Breathing
Stephen Griew
Ontario Federation of Community Mental Health and Addiction Programs
Labourers Local 183 Members' Benefit Fund
Canadian Society for Environmental Medicine
Colon Therapists Association of Ontario
Attendant Care Action Coalition Plus
Karen Kahansky and Stefan Fridriksson
STANDING COMMITTEE ON SOCIAL DEVELOPMENT
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)
Substitutions:
Jackson, Cameron (Burlington South PC) for Mrs Witmer
Johnson, Paul R. (Prince Edward-Lennox-South Hastings NDP) for Mr Silipo
Wessenger, Paul (Simcoe Centre NDP) for Mr Malkowski
Clerk: Mellor, Lynn
Staff: Gardner, Bob, Research Officer, Legislative Research Service
The committee met at 1002 in committee room 2.
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
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.
ASSOCIATION OF SOCIAL WORK DIRECTORS OF THE HOSPITAL COUNCIL OF METROPOLITAN TORONTO
The Chair: I want to welcome everyone this morning. I am going to call first the Association of Social Work Directors of the Hospital Council of Metropolitan Toronto.
Mr McNeill: Thank you very much. We represent the Association of Social Work Directors of the Hospital Council of Metropolitan Toronto. Many of you may know that the council represents 50 member hospitals that comprise a number of different types of hospitals including acute and chronic care facilities, rehabilitation hospitals, mental health facilities, convalescent hospitals and so forth.
My name is Ted McNeill. I am the director of social work at the Hospital for Sick Children and am here in my capacity as chair of the association.
With me this morning are Susan Roher, director of social work at Scarborough Grace Hospital; Jane Adams, director of social work at York-Finch General Hospital, and Beverly Abosh, social worker in chief at the Clarke Institute of Psychiatry. There is a brief bit of information about each of us appended to the presentation.
First of all, we want to thank the committee for this opportunity to present our views. We have been looking forward to this and wanted also to make ourselves available to speak with you about the issues that are of concern to us. We also want to commend the government of Ontario, both present and past, including former ministers of health and other key members of the ministry, Linda Bohnen, Alan Burrows and others who have contributed so much to this legislation.
As an association, we are very pleased to say we are in support of the legislation. We are particularly supportive of the underlying principles, the intent of the legislation to protect the public and to offer the consumers within the province a greater choice in health care services. However, we also have some concerns about the way the legislation is currently drafted. As all of you know, social work is not included as one of the professions regulated in the act and will become, when the legislation is enacted, one of the largest, probably the largest, group of professionals within hospitals that is not regulated. We think this is a serious omission that needs to be addressed.
While social work is not included in the legislation, we feel the legislation as it is written will have a serious impact on the practice of social work not only in hospitals but in other related settings across the province. We agree with the position of the Ontario Association of Professional Social Workers and legal counsel that suggests this legislation will have a chilling effect on the practice of social work in the province. This has to do with the kind of practice we are involved in. As soon as you begin to include mental health within the scope of health care services, you are into what social workers provide, and that is why so many settings other than hospitals may well be affected by the legislation as well.
We do recognize it is not the intent of the government to curtail the practice of social work or to make illegal our practice in any way and we are encouraged by the reassurances that we have had about that. However, we feel we need to speak to the legislation as it is currently written because that is how we feel a judge would be asked to interpret the legislation in a court of law.
What I would like to do this morning is speak very briefly to the role of social work in hospitals, cite a clinical example to demonstrate this and then outline four areas of concerns we have with respect to the legislation.
I will refer now to page 2 of the document you have in front of you, under the heading "Role of Social Work in Health Care," paragraph 2. If there is anything we would like to leave you with regarding the practice of social work in hospitals, it is the notion that central to the role of providing social work services in hospitals is the assessment or diagnosis of the patient's relative level of functioning. Inherent in this is identifying dysfunctional behaviour and the causes or contributing factors that maintain it. While social workers diagnose dysfunctional attitudes or behaviours or relationships, etc, our therapeutic approach is usually to identify strengths and resources and attempt to build on these. However, it is impossible to provide these services without being able to openly communicate our findings with the patient and family. It is this process we believe to be at serious risk under the current wording of the legislation. On page 3 we have identified three examples. I will speak only to the first one.
In paediatric hospitals, such as the Hospital for Sick Children where I am employed, family members often have a very difficult time coming to terms with their child's diagnosis, particularly if it is a life-threatening illness such as cancer or leukaemia. Consequently, they can have a great deal of difficulty responding to their children in the way the child needs, in a supportive and empathic manner. This may be due to many different kinds of causes. The parents' previous experiences in their own families of origin as well as other personal and interpersonal dynamics may manifest themselves as obstacles to dealing with the strong feelings of fear, anxiety and loss and so forth that get triggered in people in these kinds of situations. Unfortunately, this can be very dysfunctional. Children with life-threatening diagnoses need to be able to talk about their illnesses. They need to be able to talk about their worries and their concerns when they are ready to do that. Otherwise they can feel alone, isolated and become depressed, which becomes then a very serious complicating factor and a reason for concern in and of itself.
Under Bill 43, we believe the social worker on a team could no longer identify the underlying causes of this dysfunctional behaviour in the family and assist the child and family to adjust to their situation. This example, as well as the others cited below, supports our greatest concern with the legislation as it is currently written.
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I turn now to page 4. I would like to speak to the concerns. Of greatest concern is paragraph 26(2)1. I probably do not need to read this paragraph. I am sure you have been hearing about it from some of the other groups as well. We appreciate the difficulties here. From our perspective, we want to emphasize, however, that in health care settings an important aspect of the role of the social worker is to address the mental, emotional and social health of the patient and family. Communicating a diagnostic formulation or conclusion is essential to providing social work services. While social workers are not qualified to diagnose physical disease -- drug and alcohol addictions may require further sorting out -- they are routinely called on to assess and diagnose disorders and dysfunctions.
Currently, there is no distinction within the act between various social, emotional, behavioural and physical orders and so forth. We feel this leaves the act open to being interpreted too broadly. We feel key terms require definition. Because of the legal jeopardy this clause places on social workers, we therefore recommend that (a) diagnosis remain as a controlled act but key terms such as "communicated," "conclusion," "diseases," "disorders," "dysfunction" and so forth be clearly defined and placed in a context that would remove the risk of prosecution for social workers in carrying out their normal practice or that (b) diagnosis be removed as a controlled act if key terms cannot be adequately defined, so as to remove the risk of placing professions such as social work at risk.
A second area of concern has to do with the harm clause and our concern that it may be reintroduced. While we respect that there is a potential value in a harm clause which might catch any situations not accounted for under section 26 regarding controlled acts, we are not optimistic that a workable rewording can be found. Our recommendation therefore is that since it appears it would not achieve its purpose of protecting the public and would have a detrimental effect on social work practice, we feel the harm clause should remain out of the legislation.
These are our two main concerns about the legislation. Our last concern that we wanted to identify here has to do with the use of the title "doctor," which we believe is inconsistent and unfair as it is currently set forth. In our society, we place value on continuous learning and development. This is recognized in a number of ways, significantly through the use of the title "doctor" upon achieving the highest degree in one's profession. As written, the act is at least unfair and perhaps discriminatory to all professions and disciplines where the highest degree is a PhD.
This section of the act also seems inconsistent with the desire to recognize the expertise of a broad range of health care providers. While we acknowledge that there are many types of doctors within the health care system, we believe the onus should be placed on the practitioner to identify clearly the professional discipline within which one practises and not to misrepresent oneself. Our recommendation is that no restriction should be placed on the use of the title "doctor." Practitioners should inform consumers about their professional discipline and must not in any way misrepresent themselves. Penalties should be enacted regarding this latter scenario.
Finally, regarding the complaints procedure, we are aware, from our clinical practice with patients and families, that some members of the public may need assistance in bringing a complaint about professional practice to a college. The complaints procedure is inherently adversarial. Some availability of support and advocacy for those who need it would be beneficial. We are recommending that human and financial resources be made available to provide assistance to those who may require help in lodging a complaint to a college.
In conclusion, while we support most aspects of this legislation, we are concerned about the areas we have identified this morning. It is our strong belief that the public will not be served if its range of choice is curtailed by making social work practice all but illegal under the act. Legislation regarding social work practice in Ontario is needed. Our recommendation is that the standing committee on social development recommend to the Legislature that a social work act be enacted for the self-regulation of the social work profession in Ontario and that such legislation be made compatible with the Regulated Health Professions Act.
What I neglected to say -- and I apologize to my colleagues -- is that I was making a presentation in my capacity as chair of the association, but we are all here to respond to questions and engage in discussion.
Ms Haeck: Thank you very much for your very articulate presentation. It does, as you are probably well aware, echo the concerns of other social work groups we have had before us. I am going to ask a question that has been posed before us -- not to social work groups, to other groups -- which relates to the fact that as part of your practice, normally the patient has been seen first by a medical doctor, especially in a hospital setting. The patient is not going to come to you directly, am I correct?
Ms Adams: Not necessarily. There will be situations, possibly in an emergency department, for example, where it may be the social worker who sees the patient first; or even situations where the patient may not be the identified patient in the hospital, but the spouse of the patient; or, as Ted described earlier, it may be a child who is actually the patient, but maybe the parents who are seen as well.
Ms Haeck: In the process of coming to grips with the diagnosis clause and with the communication aspect of it, the initial medical diagnosis, the cause of the particular disease -- a broken leg or something else -- has been dealt with. But then come the recognition that there may be other family problems that obviously contribute to this person's total problem, which may not be the broken leg. There may be some reason why this person is ill -- which is where you come into play. That is usually done more on a referral basis. Right? Wrong?
Mr McNeill: Often it is done on a referral. It depends on the setting. Some hospitals require that an order be in the chart for social work involvement. Others do not. A case may be done by the social worker on the particular team that he or she is assigned to.
Ms Haeck: I am not sure I feel that it is clarified for myself.
Mrs McLeod: I have a dealing with your concern with the diagnosis clause which, as has been said, we hear quite regularly on the committee. There was a clause recommended by the Schwartz task force, which you may be aware of, that was an assessment clause that would have applied to both regulated and unregulated professions, and would have allowed for the assessment and communication of findings. That clause was not contained in the legislation, because I think that legally the diagnosis clause was seen to override it.
You have suggested the diagnosis clause be defined more completely, or dropped altogether. One recommendation the committee has heard is that the diagnosis clause read simply "diagnosis," and the assessment clause be reintroduced -- not as a controlled act, but that the controlled act of diagnosis not be defined and that the courts could in fact define that. I am not sure if that is something that your profession has looked at as a possible route, and what your comments would be on that.
Mr McNeill: I think we would still need to have clarification of the definition of diagnosis. In our language, in the tradition of our practice, we would talk about social work diagnoses. We see that as a process we engage in, where we are identifying contributing factors to whatever the mental health concern or social concern may be at that time. Based on that we would be deciding what kind of intervention would be appropriate and talking about that with the patient.
We respect that this is a very difficult situation and do not have a ready answer to it. The term "diagnosis" is one that has been used so broadly across the board. I do not know whether you are suggesting that maybe you restrict it to physical disease. Even in that case, it could present other difficulties. The split between mind and body and what is physical and what is emotional is not clear-cut. I mean, it is not just black and white. That is where some of the difficulties come in.
Mr Owens: I think you hit the nail on the head with respect to trying to draw the line between mind and body. One of the other ideas that has been put forth to the committee is that we either remove totally the word "dysfunction," or exempt groups like social workers through regulation, as "dysfunction" seems to be a term that is germane to your profession. Do you have any comments about that?
Ms Abosh: The terminology is confusing. "Dysfunction" and "disorder" are terms that we do use. I represent some of the workers in mental health, and it is particularly difficult to sort out if depression is a biological disease or whether it is an emotional disease, and whether it is a dysfunction or a disorder or a diagnosis. It is tough, and this is our concern. We do this readily. To answer one of the questions that somebody posed before, frequently social workers are the first people to see a patient, particularly in a community mental health setting.
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Mr J. Wilson: Just a very quick question on the complaints procedure. You recommend financial assistance for complainants. It is my understanding, as I read the bill, that really just a letter to the registrar is required to begin the complaints procedure. At what point do you figure complainants would need financial assistance?
Mr McNeill: It can be a complicated process once they get into it. If there was some kind of resource available which a person could access if he needed it -- and that person might have to provide some kind of assessment as to the extent of the support required and how much it would phase throughout that process. From our work, we know that even what might seem a simple referral to a welfare office for community resources is not always straightforward because of the other complicating factors that the patient may present. It is based on some of those kinds of experiences that we feel that some groups in society -- maybe those that most need support -- may not have it.
The Chair: Thank you very much for your presentation. We appreciate your coming before the standing committee this morning. I hope you realize, and I say to everyone here this morning, if there is additional information that you think would be helpful to the committee during our deliberations, please communicate with us in writing via our clerk.
COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO
The Chair: I would like to call the College of Physicians and Surgeons of Ontario.
Dr Morrison: Thank you, Madam Chair and committee members. I am George Morrison, president of the College of Physicians and Surgeons of Ontario. I have with me Michael Dixon, the registrar of the college; Jenny Coco, a public member of the council and a member of the executive committee, and Rachel Edney, the vice-president.
The College of Physicians and Surgeons of Ontario believes the Regulated Health Professions Act will usher in an era of vastly increased co-operation among health professions. We are committed to making this new system work and we will extend our help to any new profession that wishes to work with us in developing its own system of regulation. In short, we believe all of the regulated professions will be able to forge an effective partnership under this legislation which will benefit the public.
Today we would like to focus our presentation on substantive issues of policy and procedure raised by this legislation. For reference, we have circulated briefing papers and appendices to you. In order to leave time for questions, I will be only highlighting, rather than reading, this whole submission.
In protecting the public interest, our most important criticism of the legislation is the fact that it deregulates much of our health care system. As you know from the airline industry in the United States, deregulation is not always conducive to public protection. Many more professions come under the umbrella of regulation, but the umbrella will not offer much protection. That worries us, because people do not and cannot make health care choices in the same way they make other choices as consumers. When we are worried about our health, or that of a loved one, we do not operate as rationally as we do when we buy a car. The reason for regulation in health care is that we want the range of choices available to be safe and potentially effective.
That will not be the case under the proposed legislation. Reducing the definition of medicine and many other professions to a few specific acts will give untrained, unqualified people a roadmap to follow in treating patients without fear of reprisal. The harm provision was included in the initial legislation to deal with that problem.
The need for a harm provision is supported by an opinion from the Attorney General's office. That opinion is quoted in the background section of briefing note 1 that we have given you. In part it states that section 27.04, which is the harm clause, "is a vital component of the licensed acts scheme." Without that provision to plug the gaps in the controlled acts there will be no way to prevent scenarios such as herbalists wrapping babies in cabbage leaves and prescribing starvation diets, because the herbalist will be able to claim that no controlled act was transgressed.
We realize that one of the key goals of this legislation is greater choice and we support that goal. But we do not believe that any public interest group or member of the public would advocate that the health care choices freely available should include unqualified, untrained people.
We have developed a revised harm provision for your consideration, which you will find in briefing note 1. This revised wording tries to address the concerns of unregulated practitioners by excluding emotional, social and spiritual counselling.
A related issue is the need for public education. Briefing note 2 outlines our suggestions in that area: a public health care data bank, provisions to prevent people from displaying fraudulent degrees, and a truth-in-advertising requirement for all those offering health care. In addition, we believe people have a right to know whether or not a practitioner is a member of a regulated profession before they accept advice from that person about their health. Briefing note 2 provides legislative wording for a disclosure provision.
We applaud the commitment to quality management in health care that is included in this legislation. This will focus regulatory efforts where they should be -- on continuous improvement of the professions. However, we will always be faced with some professionals who pose serious risks to the public.
Our college has no effective way to assess a doctor we believe may be incompetent, unless that doctor has committed a serious enough error to be disciplined. Our only other option is to conduct an investigation under section 64 of the Health Disciplines Act, but this only allows us to review records and charts -- and doctors may not reveal their incompetence in their records. Our concerns are spelled out in the first few paragraphs of briefing note 3.
What is needed is a new system whereby a practitioner who may be incompetent can be required to go through an evaluation of his or her competence. If deficiencies in skills or knowledge are found, that practitioner can also be required to accept a period of retraining and evaluation. In briefing note 3, we expand on this issue and in appendix 2 we propose legislative wording for a continuing competence system. This is fairly complex and we can see that it may not be possible to introduce it at this point. It may be an issue that should go to the advisory council envisioned by the legislation, in order that a full and frank discussion could be held about an issue which we think is relevant to the ability of all colleges to protect the public.
In January our college commissioned an independent task force to examine the issue of sexual abuse of patients by doctors. The college received its preliminary report on May 27. The task force will be presenting its final report this fall. We are not in a position to recommend legislative changes to you today as our council has not seen the final report, nor had a chance to discuss the final recommendations. As you know, the task force members will make the next presentation to the committee regarding their recommendations, the feedback they have received and the legislative implications in their suggestions for reform.
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Maintaining self-regulation is an important professional concern. The announcement in April that public membership on college councils would be increased to just under half comes at a time when our college is doing more to reach out and involve the public in self-government than it ever has before. We have opened our council meetings and discipline hearings to the public. We have reviewed the complaints process with the direct involvement of public interest groups. We have established an advisory committee on multicultural issues. We have been pioneers in the area of peer review and have now established a program to assess a doctor's competence and identify areas of deficiency. We took the unprecedented action of establishing an independent task force to gain insight into how we could improve our efforts in the area of sexual abuse by physicians, and we have already created a committee on quality management at the college.
Our polling of the profession clearly indicates that doctors feel that the principle of self-regulation will be eroded with a council made up of almost half public members. Alan Schwartz felt very strongly about this. We have provided one quotation from the Health Professions Legislation Review. Elsewhere in the review, he also stated:
"The majority of health professionals and their organizations must be relatively satisfied with the system. They should not believe that their legitimate interests have been ignored. The system should not discourage professionals from co-operating with their colleges, because regulation based on coercion is in the long run likely to be ineffective and expensive."
If doctors no longer feel that they as a group are self-regulating, if they feel the government is accountable for medical regulation, then we believe they will also be far less willing to get involved in helping us protect the public through the college's programs.
There is no question that we are in favour of increasing public representation on our council, and we support a ratio of 60% physicians and 40% public members, but we do not believe that a council made up of almost equal numbers of doctors and lay people can truly claim to be a self-governing body.
We have already heard the view expressed by the Council of Ontario Faculties of Medicine that reducing the number of academic appointees on our council would not serve the public or profession well. We would lose the academic input on a number of committees, and I think the most important area is the task force on sexual abuse and the recommendations arising from that. We urge the committee to retain the current level of representation, one appointee from each faculty of medicine in Ontario.
We would also like to express our concern with the amendment which would sunset appointments to council after two three-year terms. We believe two four-year terms or three three-year terms would be more reasonable.
Madam Chair, let me reiterate that the college supports the thrust of this new legislation and believes that bringing a greater number of professions under the umbrella of self-regulation will give a greater sense of community to the providers of health care in Ontario and a greater level of involvement in health care for the public. We believe that the suggestions we have made today will address significant problems with the draft legislation that you have before you.
The Chair: Thank you for your presentation, an excellent presentation, I think all members will agree.
Mr Beer: Thank you very much for your presentation and for all of the other background material which we will be able to look at. I think one of the important questions we would want to raise with you concerns the functioning of the council, and particularly the participation of professionals and the public. You have suggested in your brief that perhaps the ratio of physicians and public members would be 60 to 40, and I wonder if I might ask the public member representative on your council to elaborate a bit on how you have come to see that balance in terms of the council being a truly self-regulating, self-governing body, and if you believe that there is a need to make further changes. Is there something between -- I guess a third was the original proposal -- between that and 48% or 49%, the 40% sounds like it has come down the middle. From the public's perspective, could you set out how you feel that would continue to ensure public input and yet be a better self-regulating body?
Ms Coco: I think we have to remember that there has to be a partnership develop between the physician members of council and the public members of council. To date we have not had the problem of voicing our own concerns to the council members, both medical and non-medical, and we have always had an effective voice on council; but to work effectively, I think we have to have the partnership. If ownership is important to the medical profession, then I think the compromise of partnership would make it more effective for the public representatives.
Mr Beer: What would we be talking about then, just for the record, in terms of the numbers who would be on council, and how many of those would be public members?
Ms Coco: Presently we are proposing 40%, which I believe is in appendix 4. With that ratio, we are proposing the number of elected doctors be 16, the number of academic appointees 5 and the number of public 12.
Mr Beer: You note in the specific proposal that the legislation would perhaps use permissive wording, so that, "the minister may appoint up to 15 lay members," and I take it that would be to provide flexibility from your point of view.
Ms Coco: Yes.
Mr Owens: Dr Morrison, regarding your presentation on the quality of medical care, you make a statement about wanting to protect the public against "cabbage leaf wrappers," and then in your comments you also make a comment that you have very limited means of assessing your own physicians. I am wondering if you can tell me, within the last 10 years, how many members of your own profession have actually faced disciplinary proceedings for breach of practice, versus the number of the cabbage leaf wrappers of the non-traditional practitioners of medicine who have been prosecuted or in some way disciplined?
Dr Morrison: I am going to ask the registrar for that.
Dr Dixon: In terms of members of the profession who have gone to discipline on various charges, we are averaging approximately 80 hearings a year. It has increased in the last few years and currently we have quite a substantial backlog that we are working on. In terms of prosecution for what is generically known as the illegal practice of medicine, be they unrecognized, untrained practitioners or in some rare cases people who are registered in other professions, this has averaged one or two cases a year over the last decade. That information had been summarized and had been provided to Mr Schwartz during the course of his review.
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Mr J. Wilson: Thank you very much for your interesting presentation. Just to pick up on what Mr Beer was alluding to concerning the number of lay appointees to council, I can understand your concerns that increasing the number of lay appointees to just under 50% may erode the principle of self-regulation. Do you not think that in the long run, with people entering the medical schools knowing that this is the case in the profession, it may lead to greater public confidence in the profession?
I just think that in the bad press surrounding the sexual task force, and certainly among constituents, you had people questioning the medical profession. I think people generally, probably our constituents, the average person on the street like the fact that they will have more say in the regulation and the running of the college, for instance. Do you want to comment on that? Certainly the thought is out there that in the long run this may be good for society.
Dr Morrison: I guess I come from a sense of responsibility as a professional, both to my patient and to my profession. We do have a responsibility to insist that all of us measure up to an acceptable standard of care and concern. I think that is what self-discipline is about. I must admit that there used to be an argument that only doctors knew how to deal with it, but there is an increasing sophistication in society that the public does have a role to play in this, and I strongly embrace that concept as well.
I still think that we as a profession have performed well in this society. I think the leadership given by my predecessors on the executive in the last few years has been particularly proactive. I think the benefits of a self-disciplining profession, not just medicine but all the others, should also be looked at. I think there are benefits to the government in terms of arm's length. I think there are benefits to the public if it has confidence in the fact that the professions are self-disciplining.
You may say that confidence has been shaken a bit. I think you could argue that we ourselves were the ones who identified the need to explore the sexual abuse problem and it reflects, to our credit, that we did face a very difficult issue. On balance, I think a sense of self-pride as a professional is important. The public should be happy that we have professionals like that. I think that all three parties -- government, public and profession -- benefit from the concept of self-regulation as it exists.
Mr J. Wilson: Thank you, I appreciate your comments on that. You mention in the brief that the minister has increased powers, and I can tell you that I think the committee, as we are relatively new to this sort of thing, to be truthful about it, and we are lay people, elected representatives, may not have a sense of what the powers of the minister were and are. Do you want to comment on that? I think your contention is that there is greater public protection because one of the factors is that the minister has increased powers in this new act?
Dr Morrison: I wonder, Michael, if you might give a cleaner answer to that.
Dr Dixon: Well, very briefly; I can see the Chair staring me in the eye.
Mr J. Wilson: She does that all day.
Dr Dixon: Under the existing act, the Minister of Health has the authority to request the councils to do various things. In particular, the minister has the responsibility to request the council to make a regulation. If the council refuses to make the regulation within a period of 60 days, the minister has the authority to make the regulation herself. Under the new legislation, that time period of 60 days is removed and the minister has the authority to require the council to make a regulation and in fact do anything else that the minister, in his or her discretion, feels is indicated in the public interest.
So in fact in the new proposal there is much greater direct authority. Under the current legislation, I do not think any council was under the illusion that it was an autonomous body and free to take on any activity or deny any activity that it felt appropriate. The councils now simply have more direct accountability, and also the minister has more direct authority over the councils.
Mr Johnson: With regard to the per diems paid to the members on the council, are they uniform? If they are not, I was wondering if you could give me some range as to what the per diems are.
Dr Morrison: The public members are paid by the government and the council members, who are professionals, are paid separately. That varies within each of the colleges. I know that the dentists, because their office expenses are considerably higher than ours, pay their members more to serve than we are paid. Our per diem is in the area of $600 and the public members are I think in the area of $125.
I think it is a very difficult issue as to how government should pay for these services. Many of the people who are participating are there I am sure because of a sense of public responsibility. They feel that it is an important contribution they are personally making. There are advantages of being able to come to Toronto. I do not see many, but some people like to do that.
Mr Johnson: Nor do I.
The Chair: We appreciate your coming before the committee this morning and we appreciate your excellent presentation. I would like to thank you, and we know as well that if there is additional information that you think would be helpful to committee members, you will communicate further with us in writing. Thank you for coming this morning.
TASK FORCE ON SEXUAL ABUSE OF PATIENTS
The Chair: I call now the Task Force on Sexual Abuse of Patients. We have all received a copy of your presentation.
Ms McPhedran: Before we begin I just draw to your attention that you have the presentation we are making, plus the list of recommendations from the preliminary report which may be helpful later. If you lose this part and do not include it with the other part, you are not going to know where it comes from because it does not have a heading.
The Chair: For your information as well as everyone else, all of the documents received by the clerk on behalf of the committee become part of the public record.
Ms McPhedran: Let me begin by introducing myself and my colleagues. My name is Marilou McPhedran. I am the chairperson of the Task Force on Sexual Abuse of Patients. Someone you have met already, Dr Rachel Edney, is also on the task force, as well as on the executive of the College of Physicians and Surgeons of Ontario. Pat Marshall is the on-leave executive director of the Metro Action Committee on Public Violence Against Women and Children, and now the co-chair of the new National Commission on Violence Against Women. Dr Harvey Armstrong is very dedicated to being, as he says, the token male on the task force and, as we constantly remind him, he has time and time again demonstrated skills and expertise and has shown that this is an issue for men and women to deal with and to be very concerned with.
Because of the shortness of time, we do not propose to read this word for word. We want to say a few words at the beginning about philosophy, and I am going to be asking my colleagues to say a few words on that. Then I can take you very quickly through the main points about actual amendments to the code that we want you to consider. We are hoping we can do this in half of our time, to leave half for questions. If you could guide us, that also would be very helpful.
I am going to ask Pat to put in context the recommendations we are making, making them consistent with a philosophy and a commitment to zero tolerance. I will just bring to your attention, before Pat speaks, the last page of our presentation, which is a July 11 letter from the Premier. We were absolutely delighted when he wrote to us to say, "Our government is also committed to zero tolerance of sexual abuse."
Ms Marshall: In December 1985, the board of directors of Metrac, the Metro Action Committee on Public Violence Against Women and Children, agreed reluctantly to my suggestion that we participate in the health professions legislation process and discussion because sexual abuse by health professionals was not an issue that seemed to be addressed very effectively according to the public hearings we had had and a task force from 1982 and in our work.
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The terminology of the old Health Disciplines Act that talked about sexual impropriety, even that euphemistic term, we recognized as problematic to cover rape and sexual assault. We were hearing on a regular basis instances of sexual abuse by health professionals that did not seem to be dealt with very effectively by either the criminal justice system or by self-regulating professions.
As a result of that, we began a process that has ended up with both Marilou McPhedran, from the board of directors of the Metro Action Committee on Public Violence Against Women and Children, and myself working with the college in its leadership role in pointing the direction of self-regulation and in dealing with sexual abuse involving a breach of trust.
Zero tolerance of sexual abuse is something that almost everyone we have talked to subscribes to, but what we have tried to do is articulate what it means in terms of policies, practices and procedures. No one will admit or support sexual abuse in the first instance, but what in fact was happening was that because there was not a very clear recognition of how pervasive it is, what the impact is, what it really involves, there were no processes and policies in place that were responding to it.
That is one of the main things we have tried to do, that is, try to name the experience, name the response in the clearest, most unequivocal communication possible. As you will know, the council of the College of Physicians and Surgeons has adopted already unanimously this philosophical foundation.
It is the litmus test. It is the basis upon which all the other recommendations come, and we encourage you to think about zero tolerance of sexual abuse in your own discussions of these regulations, and also to keep in mind, although the charter does not formally apply, the spirit of the charter and that right to equal benefit and protection of the law that must extend to sexual abuse survivors as well as to others in our society, including the professionals.
Ms McPhedran: We would also like you to consider one of the most discussed proposals that we have made: the current definition of sexual impropriety as a form of professional misconduct, that is in the Health Disciplines Act. We would like you in your deliberations to consider our proposal about the change that should be made, which is to create two offences: to clearly define sexual abuse as an offence and also to define sexual impropriety separate and apart from being just one of a list of over 30 examples of misconduct and instead to place it on its own, along with sexual abuse. You will find this at page 7 of our presentation where we outline our proposal.
The final report of the task force will be available later this fall. It is likely that we will be making some modifications to this proposal, but we will not be making any change to our basic proposal here, which is that these two offences should be placed within the RHPA and the HDA, if that is necessary.
In order to place in context for you the importance of this proposal, I am going to ask Dr Armstrong very briefly to give you some information about his own practice with sexual abuse survivors and why this proposal is appropriate.
Dr Armstrong: When patients go to physicians and they experience demeaning language, sexist behaviour, humiliating draping, destructive comments about their underwear or clothes, they really get frightened and turned off health care. Sometimes, in the time we have been travelling, we have run into people who have had to travel hundreds of miles to get health care in small communities because this is what routinely happens in their practice. I think that is due partly to ignorance, partly to just not being sensitive. That process, those kinds of behaviour, need to be stopped, and we are very clear that is not done quite as maliciously and destructively as sexual abuse.
Sexual abuse is much more serious; it is behaviour really that involves exploitation of patients. It is not clumsiness. It is not stupidity. It is not lack of knowledge. It is not lack of sensitivity. It is exploitation of people for the physician's purposes, and that is much more serious.
The kind of behaviour we have encountered in the process of going through the hearings, and in my practice, includes people having sexual intercourse with physicians in their hospital beds, having years and years of prolonged and humiliating sexual abuse, and patients going back and back, partly because there may be no other resource available to them for medical care and sometimes because they just hope this abuse is going to turn into love.
You must remember too that many people who are abused by physicians are victims of childhood sexual abuse and are very easy to victimize. These exploited people generally are very often victimized. If you look in the histories of people who are abused by health care providers, in the research that exists, most of them but not all of them, a significant majority, have been abused as children. Their response to the physician's sexual advances is partly due to the childhood exploitation and partly due to the fact the physician has trust, power and knowledge and is respected excessively.
Ms McPhedran: Would you like to proceed to questions or would you like me to go through and just highlight the code sections we are addressing?
The Chair: The time is yours and we have time for whichever you would prefer. I think the committee members would very much like to ask questions.
Ms McPhedran: I will very quickly summarize.
One of the recurring themes in this presentation is the need for greater participation of the patient in complaints hearings, in the disciplinary process. There are a number of proposals for amendments to the RHPA code which address that.
In addition to that, we say it is very important that you categorically create the right of access to medical files for all patients, not just patients who have their files in psychiatric facilities.
We are very concerned that the current time period proposed, six months before the complaints committee receives the complaint and makes a decision, is longer than the college currently takes. We feel it is perfectly adequate to go to 120 days to reflect the existing reality. Those 60 days can make a very big difference for both the patient and the doctor, who are extremely anxious. The faster the system can move, the better.
We look at section 30 of the code and ask you to pay particular attention to vulnerable witnesses. As a very high-ranking lawyer in the Ministry of the Attorney General said to us on Friday when we met, a vulnerable witness is a vulnerable witness, whether it is a child or whether it is someone who is suffering from post-traumatic disorder as a result of assault.
On the matter of public members on the discipline committee, we are looking at section 38 of your code and we feel you should very clearly require that the public member be there throughout the hearing process and not simply for a hearing to commence, so that you may be sure the participation of the public member enhances the entire proceeding and is not just pro forma.
Looking at prejudice towards the patient complainant, we are asking that section 39 be reviewed in light of the research now available about post-traumatic stress disorder.
Section 41 needs to be reviewed in light of the emphasis only on disclosure to the defence, thereby giving no opportunity in advance of the hearing to the college or to the patient to prepare for the defence. This is an administrative tribunal. It follows civil proceedings and it is absolutely not necessary to continue to import this notion, which is essentially a criminal notion, that the defence does not need to be disclosed in advance of the hearing. It results in inefficiencies and it results in injustice.
Section 63 of the proposed code carries through what is in the Health Disciplines Act and talks about the fitness to practice committee having the right to specify "any person" as a party. We are saying the same power that you have for the fitness to practice committee should be extended to both the complaints committee and the discipline committee, thereby providing the most effective way in law to increase the participation of patients in the process.
At page 4, we talk about the survivors' compensation fund. This is a brand-new concept. One of the rather amazing things we have discovered is that although lawyers established a compensation fund for victims of lawyers who had bilked their clients and had been found guilty of so doing almost 40 years ago, no such thing has ever been done by the doctors in this province to compensate their victims in any way. We are saying that it is high time the medical profession assumed its collective responsibility and established such a fund, and we lay out our proposal there.
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We also point out that section 50 of the code should be amended to include a much greater fine than is allowed for incompetence, as well as for other offenses which already do have fines attached to them, and this money should go to the compensation fund. It should be there to allow for genuine attempts to compensate in some way for the enormous damage that has been done.
On section 69, we ask that sexual abuse be included as a ground of incompetence or incapacity. Once again, it is just to integrate sexual abuse throughout the code to make it possible for all the various permutations and combinations of facts to be covered, using the code. On the limitation period, we refer you to the March 1991 report of the Attorney General that recognizes that "In some circumstances, the sexual assault will render the victim incapable of considering legal proceedings until many years after the event." Change the code of RHPA to reflect this reality. Do not keep your one-year limitation period, which only acts to the benefit of the abusing doctor.
Increased public representation: we have made some mention of that. Disclosure of all parties: we have made mention of that. We have also talked about delay as a form of injustice. We invite any questions you may have now with the short time that is available to us.
Ms Haeck: This is an extremely timely presentation and I would like to refer you to the College of Physicians and Surgeons of Ontario presentation and your comments with regard to public representation on the college of physicians and surgeons. Do you view the near-50% representation on the college of physicians and surgeons in the same light as the college does?
Ms McPhedran: I do not think we took a clear position on that. To be honest with you, I was not in the room when the presentation was made. It was standing room only when that part of the presentation was made. Certainly our report has reflected and will continue to reflect a very clear commitment and a support on the part of the task force to increase public representation in this process. One of our recommendations, for example, is that there should be clearer direction in the code and RHPA to have more public members on the committees. Logically speaking, if you are going to do that, then you need to have more public members than currently sit on the body.
Mrs McLeod: I would not like to ask a specific question without first stating a complete acceptance of the philosophy that Pat Marshall outlined in the introductory remarks: respect for the work the committee has done and appreciation of the college of physicians and surgeons for having set up the independent task force. I think it is appropriate to put any specific questions into that context. I did want to ask a question about the definition of sexual abuse, which I am sure has been a cause for considerable discussion among your committee members.
It comes back to Pat's comments about the importance for absolutely clear communication and understanding. I am sure the question of whether or not it is difficult for the patient to know what is appropriate and necessary as part of a standard medical examination, is an issue of clear communication, particularly as it should be quite clear in terms of sexual intercourse and kissing, but less clear as you get to the definition of touching breasts and genitals. Could you say a little bit more about this whole question of the clarity of communication in that definition and whether, for example, the recommendations about brochures, indications of what warnings patients should be looking for will adequately address this question of the confusion that may exist in the patient's mind?
Ms Marshall: We all could respond to that. In our hearings we heard women who were absolutely clear -- and I am quite convinced that both women and doctors can be absolutely clear -- about what is appropriate touch and what is not. The majority of doctors, when we talked to them, have no question at all about what is appropriate and they are confident that they can communicate that to the patients. As we talk to women, they are pretty clear and I have not heard confusion about inappropriate touch. There are things that have felt inappropriate which they have questioned and then questioned the bad feelings they have had afterwards. I think there is often some need to validate that those feelings are absolutely appropriate because it was inappropriate touch. But we found it is not an issue around which there is confusion and the misinterpretation of appropriate medical practice as inappropriate.
Mr J. Wilson: Thank you for the presentation. Your recommendation 24: As you know, my colleague Ernie Eves introduced a private member's bill dealing with sexual abuse. As a caucus, we are very supportive of that. Just as a point of process, perhaps you could clarify it for me. In the new act, are you asking us to include these definitions? I am just wondering about the timing. Your final report comes out in the fall and we are making our deliberations now and going into clause-by-clause in mid-September.
The Chair: After the House returns, which is September 23, likely through the month of October.
Mr J. Wilson: Do you want to comment on that? We may be pre-empting.
Ms McPhedran: I did try to address that a little bit when I said that while we may make some modifications in wording, we will not be modifying the concept of two levels or the use of the term "sexual impropriety," the use of the term "sexual abuse" and the indicators that we have mentioned. What we are saying to you is that there is not going to be a significant change in the final report from the preliminary report in this area, and we invite you to further your own deliberations. We hope we have pointed you in the direction to go. It is certainly open to you as a committee to seek further advice and to develop the definitions as you see fit.
Ms Marshall: In terms of penalty, if I may just address that, because we have not mentioned that at all, it is important and we urge you to consider the literature on rehabilitation. It is not, at this point, possible to identify prospectively rather than retrospectively a doctor for whom any rehabilitation program is successful. That we are quite clear about in our review. It is impossible to tell, among those who have gone through the program prospectively. Given the tremendous power, privilege and position of trust that is given, we have very grave concerns, obviously, about reinvesting that when we cannot tell ahead of time, because of the very early stage of development of rehabilitation programs, which doctors rehabilitation is going to be successful for.
Mr J. Wilson: That is a very good point.
The Chair: With consent, maybe I would just like to put one question on the record. Perhaps through written brief and submission you could inform the committee at a later time. Your work was done under the auspices of the college of physicians and surgeons. There are many other health professionals who, I believe, would want to address this very significant issue as well. How would you propose that under this legislative framework? I am not going to ask you to answer that today, but I think that is a question all committee members would like you to consider and submit in writing. There will be an opportunity with the final presentation of your brief this fall to give us your advice on that.
Ms McPhedran: Madam Chair, recommendation 20 of the preliminary report is that, although the task force was only commissioned to look at the medical profession, we see absolutely no reason why any of the recommendations that you have before you today from the task force should not apply equally to the other health professions governed by the RHPA. That is our recommendation to you. I think that gets wrapped up as a package. We really think this committee has an exciting opportunity to look at a code of conduct in the procedures that relate to sexual abuse victims in all the health professions. There may well be areas where some of the procedures need to be fine-tuned to reflect what we now know to be the actuality of rape trauma syndrome, post-traumatic stress disorders and what that means in changing our procedures and reflecting the reality of patients who have been sexually abused in any health profession.
The Chair: Did you have any representation made to your task force from any of the other professions or colleges?
Ms McPhedran: We have received a number of written briefs from other professions that are to be regulated under this bill, yes.
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Mr Owens: Madam Chair, with further permission of the committee I would like to ask whether we could also have some thoughts with respect to the use of an advocate by complainants, especially when you refer to the vulnerable patient, recognizing that we are trying to make the system as accessible as possible but due to the nature of the issue we may lose some folks and we clearly do not want to do that. How would you see the role of an advocate assisting in getting the complaints filed and "prosecuted"?
Dr Edney: I think we would be very comfortable with that. We have recommended that the complainant should have support. I do not know whether that is quite the concept you have of an advocate, but the complainant should have support throughout this process and an advocate should be with the complainant at the college. We have an advocate, actually; we have somebody at the college now who is a college employee and is there to help patients. Somebody from outside to support the complainant, paid for by the college would be something we would support.
The Chair: Thank you very much for an excellent and very significant presentation before the committee today. As I have mentioned to others, we hope you will communicate with us in writing if there is additional information you think would be helpful to committee members as we continue our deliberations.
The committee recessed at 1112.
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COLLEGE OF OPTOMETRISTS OF ONTARIO
The Chair: I call the College of Optometrists of Ontario.
Dr Garnett: Thank you, Madam Chairman. With me today are: Irving Baker, registrar of the college; Bud Cockerton, a public member of council and also a member of our discipline committee; Ross Morrison whom I will introduce more fully later. My name is Brian Garnett. I practise in London and am president of the college. As you know, the college is the regulatory body of the profession of optometry. Its authority to govern its members is given by the Health Disciplines Act. The profession of optometry has been governed by provincial statute in Ontario since 1919. As a result, the college has gained considerable experience in the regulation of the profession and in the administration of its statutes.
We have carefully studied Bill 60 and Bill 43. Our comments today, we hope, will reflect the recognition of our responsibility; that is, to act in order that the public interest may be served and protected. Our written submission is in two parts. Each contains recommendations to the committee. Part one deals with our concerns with the scope of practice definition and the authorized acts in Bill 60. These elements, as you know, serve to define the profession of optometry. Part two deals with legal and procedural matters. In Bill 43 there are a number of improvements we think can be made to improve the administration and the effectiveness of the statute. Our oral presentation today will deal only with part 1, the definition of the practice.
An accurate, statutory definition of a profession is absolutely central to self-government of that profession. Bill 60, as drafted, does not accurately define the profession of optometry. Omissions in the scope of practice statement and the authorized acts lead to that problem. In preparation for this presentation, we obtained the written submissions to this committee from other optometric groups. You are aware no doubt that the overwhelming concern was with a reduction in the scope of practice of optometry that would occur. The college is in complete accord with the opinions expressed by these other groups. Optometrists would not be able to provide the services they have in the past.
I would now like to introduce Ross Morrison. Mr Morrison is a lawyer in the firm of Shibley, Righton. He acts for the College of Optometrists of Ontario before the discipline committee. He acts in the same capacity for other colleges. We have asked him to share with you his opinion on the implications of the proposed legislation in these critical areas.
Mr Morrison: In my capacity as counsel to the college, with particular emphasis on the prosecution of charges of professional misconduct before the discipline committee of this and other colleges, I was asked to provide my opinion with respect to the interpretation of certain provisions of the Regulated Health Professions Act, Bill 43, and its companion legislation, the Optometry Act, Bill 60. More specifically, I was asked to consider the controlled acts provision of the Regulated Health Professions Act and the scope of practice and authorized acts provisions of the Optometry Act.
At the outset, it must be noted that a controlled act, under the Regulated Health Professions Act, includes communicating to an individual a conclusion, identifying a disease, disorder or dysfunction as the cause of symptoms of the individual. On the other hand, both the scope of practice of optometry and the authorized acts which an optometrist may perform, as defined in the Optometry Act, include diagnosis, treatment and prevention of vision and oculomotor dysfunctions and the communication of a conclusion identifying a vision or oculomotor dysfunction of the eye, but they do not include diagnosis, treatment and prevention of diseases or disorders of the eye or the communication of a conclusion identifying a disease or disorder of the eye as the cause of a person's symptoms.
I have expressed to the college my opinion on the fact that the Optometry Act is silent in identifying diseases or disorders of the eye as within the scope of practice of an optometrist and within the authorized acts which an optometrist may perform. My opinion is that such silence will likely adversely impact the ability of the college to administer the statute to maintain the standards of practice of the profession and ultimately to protect the public interest.
Identification of diseases or disorders of the eye or vision system and the communication of such conclusions by an optometrist to his patient are integral parts of the practice of optometry. I have several reasons for expressing the opinion which I have so expressed to the college.
A practitioner is obliged to provide services to a patient in accordance with accepted professional standards of practice. In the context of insured services for which payment to the practitioner is made by the Ontario health insurance plan -- this obligation is codified in section 24 of the Health Insurance Act -- the Divisional Court has ruled that the standards to be considered are those of the profession itself, drawn not only from the regulations under the Health Disciplines Act, but also from advisory notices which the college publishes and from expert evidence.
Those advisory notices include the manual respecting the clinical practice of optometry which is now the guide to the clinical practice of optometry that is published by the college. It is distributed by the college to its members and it provides very clear guidelines relating to both diagnostic and treatment services. Those guidelines are not limited only to determining and communicating vision and oculomotor dysfunctions of the eye. There are regulations under the Health Insurance Act, specifically section 47, which define certain services rendered by optometrists and insured services under the Ontario health insurance plan.
Before those regulations were amended in April 1989, the insured services included oculovisual assessments, V401; oculovisual reassessment, V402; partial oculovisual assessment, V403. Since April 1989, those insured services have been redefined and limited to what is referred to as a first oculovisual assessment, and it is still identified as a V401, and a follow-up oculovisual assessment, again a V-402. But it is noteworthy that under both the old and the new regulations oculovisual assessment includes, and I am quoting from the regulation, "the presence of any observed abnormality in the visual system," which in my view necessarily includes not only dysfunctions, but also diseases and disorders of the eye.
In a similar manner, sections 23 and 36 of regulation 450 under the Health Disciplines Act oblige a member to exercise generally accepted standards of practice and procedures in determining the physical, optical, sensory and oculomotor state of the eye and adnexa and in the assessment and care of the patient's vision. The member must, in addition, make and keep clinical records. Those records must detail all examination procedures used, clinical findings obtained, treatment prescribed and provided.
The regulations do not limit the findings of the member with respect to the state of the eye, to vision and oculomotor dysfunctions, but rather they impose upon the member the obligation to diagnose, communicate and record not only dysfunctions, but also diseases and/or disorders which are discovered in the course of determining, as the regulation words it, physical, optical, sensory and oculomotor state of the eye.
The role of an optometrist in the assistive devices program of the Ministry of Health is, in my view, also significant. The ADP, as you know, provides financial assistance to visually impaired residents of this province, among others, for the purpose of obtaining specified low-vision aids. The ADP recognizes optometrists as authorizers of low-vision devices. In that capacity, optometrists must provide not only a primary diagnosis, but also a secondary diagnosis if any, for example, cataracts, cerebral palsy. Arising out of this obligation upon optometrists under the ADP, is in my view a recognition and acceptance that the scope of practice of the optometrist includes diagnosis and treatment not only of dysfunctions, but also diseases and disorders of the eye.
I have advised the college that the application and interpretation of the legislation as proposed, and specifically with reference to these sections which I am addressing, raises concerns with respect to the successful prosecution of members on charges of professional misconduct before the discipline committee of the college. A member who has been charged with professional misconduct, for example by failing to maintain the standards of practice of the profession, may raise as a defence thereto that the charge involves a disease or disorder and not a dysfunction of the eye and is therefore outside the scope of practice and the authorized acts of the member.
In summary then, it is my view that under the current legislation and regulations as presently in place, the practice of optometry includes the diagnosis and treatment of diseases, disorders and dysfunctions of the eye. The legislation as proposed will limit the scope of practice of optometry to diagnosis, treatment and prevention of vision or oculomotor dysfunctions of the eye and as such is inconsistent with the historical pattern of the practice of optometry in the province of Ontario.
The new legislation, in my opinion, will redefine the scope of practice, and with it, the generally accepted professional standards and practice of the profession and will consequentially impair the ability of the college to maintain the standards of practice of the profession and ultimately to protect the public interest.
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Dr Garnett: I would now like to address your attention to page 2 of our brief. There you will find our recommendations on the scope of authorized acts. These recommendations would, we feel, properly describe the practice of optometry; retain the status quo, in other words. These recommendations were approved by council one year ago.
You may notice that the scope-of-practice statement looks familiar. It is in appearance almost exactly the one you were given two days ago by Brent MacInnis of the ophthamology section of the OMA. They agreed that the scope of practice statement in Bill 60 is too restrictive. Their suggested scope statement has one extra word "refractive." That is, optometrists diagnose, prevent and treat refractive diseases and disorders of the eye. Unfortunately, the phrase "refractive diseases" just will not work.
You heard and we agree with the statement made by Alan Burrows in London. He said that considerable progress had been made toward consensus on a scope definition. You are seeing how close we were to consensus. The residual issues were, was any modifier necessary, and if so, what was the right word or phrase? As you see, our recommendation is that no modifier is necessary and here is the reason. There are controls beyond the scope of practice statement in the authorized act to prevent practices which exceed the recognized limits of the profession. These controls are found in the regulations and in the standards of practice. For example, there have been no qualifiers in the Health Disciplines Act in 17 the years of administering that act. There just have not been problems with members exceeding the recognized scope of practice.
I have to tell you something that happened this morning. I did not sleep particularly well. I was out running at 6:30. Running through my mind were disease, diagnosis, dysfunction, refractive.
Interjections.
Dr Garnett: Yes. A light came on, and I hope you are as excited about this as I am.
The Chair: This is really exciting stuff.
Dr Garnett: Well, for us it is. By moving one word, the word "refractive" in the definition that Brent MacInnis gave us, we have a description of the scope of practice of optometry that is perfect. I checked with two legal counsels this morning, and they are entirely satisfied that this does describe the practice of optometry. We appended to your brief a page at the back which gives you that definition. It was just inserted this morning, and we think it does the job perfectly well.
In summary, then, on the scope-of-practice issue, every group that you have heard speaking on Bill 60 agrees on one thing: The scope-of-practice and authorized acts do not accurately describe the practice of optometry; second, we are within one word of solving the problem, and finally, we offer our complete co-operation with this committee and with the ministry to achieve a solution. We have also provided you with a number of amendments to Bill 43 dealing with legal and procedural matters that we think will result in improved legislation.
I thank you for your attention and for the opportunity to appear today; we would pleased to entertain any questions.
The Chair: It is not often that the committee responds with humour; and it is appreciated.
Mr Cordiano: I want to go back to the legal opinion -- obviously, that is where the crux of the matter lies -- and ask if you will give me an example of the distinctions between what is in the scope of practice, which is the identification of a dysfunction, versus the disorder and disease, which is not in the scope of practice, as I understood it. Could you give me an example of how that might arise and how you might make that distinction?
Dr Garnett: Depends on what may be considered to be a disease or disorder as opposed to a dysfunction.
Mr Cordiano: Exactly.
Dr Garnett: I wonder if Dr Baker might address that issue.
Mr Cordiano: In general terms, of course, without getting too specific.
Dr Baker: Let me make a comment. I am sure you have heard this from other groups. One of the major problems is in fact to make a distinction between disease, disorder and dysfunction, because all you can really get out of that is opinion. I can tell you what I think the disease is, or disorder or dysfunction, but that may not necessarily be the opinion of someone else. The real problem, at least from a practice point of view and a statutory point of view, is that very often if you take the act technically, you do not know whether you are dealing with a dysfunction or disorder or a disease, because my opinion is that dysfunctions are the result of diseases and disorders. It is a very complicated business, and I cannot give you a direct answer. I can give you a name. A person has blepharitis; that is considered to be a disease. You know, that kind of thing.
Mr Cordiano: Your scope of practice -- in your opinion, it is very limiting, obviously.
Dr Baker: That is right.
Mr Cordiano: And then I would turn to legal counsel for the ministry and ask was that the intention of the review with respect to the scope of practice?
Mr Wessenger: I will refer that to counsel, though my complete understanding is that there is no intention to restrict, but just to have the existing scopes of practice continue. But I will ask legal counsel to refer more specifically.
Ms Bohnen: The challenge the review had was to find the right terminology within the framework of its model to capture accurately what optometrists and other practitioners with their statutes, do. It is usually but not always easy to agree on the activities that the professionals perform and the actual specific conditions where they interact with patients. It is much more difficult to capture the right legal terminology or statutory terminology that reflects that accurately.
The review believed that the most accurate way of describing what optometrists do is that they have a very broad assessment capability, and that is reflected in the review's recommendation. However, in terms of diagnosis, their capability is more limited. The profession obviously disagrees with that. I think there is consensus at least between the optometry profession and the ophthamology profession, that they do, indeed, diagnose some diseases and disorders, but not all of them. You are hearing from the optometrists that other mechanisms such as the self-discipline of the profession are sufficient to confine optometrists to diagnosing that which they are properly qualified to diagnose. The government's view is that the statute should also set out that which they are capable of diagnosing and that it simply is not all diseases, disorders, dysfunctions.
Dr Baker: I think the brief comment is that no member of any discipline is capable of diagnosing everything.
Mr Hope: I can relate to what you are saying about jogging and thinking about this. Some of us have to jog for others who do not jog. I see a number of colleges and other people getting legal counsel. I am wondering about the changes to legislation and being more in the public's eye. Are you worried about turf battles among the colleges or are you worried about the general public's perception about what is going to happen? I am just wondering why so much legal counsel in this whole --
Dr Garnett: The scope of practice definition is so central to everything this college does, and the college's mandate is to serve and protect the public; if we do not have a proper definition, we cannot carry out that mandate. It is as simple as that.
Mr J. Wilson: I was just wondering, can ophthalmologists live with your falling off your horse this morning?
Dr Garnett: I did not meet one on my run, so I cannot reply to that question.
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Mr J. Wilson: There is terrible confusion between opticians, optometrists and ophthalmologists, and probably the most confusing part of the whole process is you guys.
Dr Garnett: I can understand your concern. I realize it is confusing, and I can see where it has been a very difficult job for ministry officials. We sympathize, and as I said, we will do our best to get a result that will operate in the public interest. That has always been important.
Mr J. Wilson: Just quickly, will you be chatting with ophthalmologists --
The Chair: Order. Thank you very much for your presentation this morning. We appreciate you appearing before the committee.
ASSOCIATION OF CHIEF PSYCHOLOGISTS OF ONTARIO SCHOOL BOARDS
The Chair: I would now like to call the Association of Chief Psychologists of Ontario School Boards. I would remind everyone that they can continue to communicate with the committee any additional information that they feel would be helpful at any time through our clerk.
Dr Blackstock: My name is Edward Blackstock, and my colleague is Lynne Beal. We are chief psychologists with school boards in Ontario. I am the president of the association, and Lynne is the secretary. I will start by thanking you for providing us with the opportunity to address the committee today on behalf of all the chief psychologists for all the school boards in Ontario.
As chief psychologists in school boards, we are responsible for the provision of psychological services that are delivered by a very large number of practitioners to children in Ontario schools. Our staff includes both registered psychologists and their associates who work under our supervision. It is our responsibility to ensure that the psychological services delivered by our staff meet the standards of practice for the profession, for the protection of the children and their parents who are our clients.
We support very much the proposed Regulated Health Professions Act. We believe that accountability to the public, protection of the public and efficient and effective service are essential components of standards of practice for psychologists. However, we have some concerns about the RHPA and the proposed Psychology Act and will outline those for you.
Section 15 of the Psychology Act restricts the use of the title "psychologist" to members of the College of Psychology, only when such members are "offering to provide, in Ontario, health care to individuals." Psychologists practising in school boards are currently regulated by the Psychologists Registration Act. The new Psychology Act, as it now stands, would exclude psychologists who work in school boards, and in effect would deregulate them. We believe that this exclusion would not be in the best interest of the public for the following reasons.
Dr Beal: The first one is that the majority of children in Ontario who receive psychological services receive them at school through psychological services departments of school boards. Our clients range in age from four years old to 21 years old. Many of these children, adolescents and young adults are from families in lower income brackets who cannot afford to pay for psychological services through private clinics. Many of them are resistant to seeking psychological services through a mental health facility because of the implication of mental illness associated with the facility. These families willingly accept referrals for the same services at school. They appreciate the convenience in accessing the services and the lack of fees.
If psychologists working in school boards were eliminated from control of the act, these children and their parents would not obtain the protection and assurances of quality of services that are provided by psychologists who are now regulated under the act.
Dr Blackstock: The second concern is that the consequences of incompetent psychological services to children are very serious and could affect the child's entire education and life, and in fact be life-threatening in some cases, of which we will give a concrete example at the end.
Children do not refer themselves or seek out the services of psychologists on their own. They are referred to school psychologists by school board personnel, teachers, principals, guidance counsellors, and they get services with the parents' written consent, of course. The children who are our clients are extremely vulnerable, as they are unable to make informed choices about psychological services for themselves. It is essential to provide them with high quality, regulated psychological services, and with a procedure for recourse in the event of malpractice. The exclusion of school psychologists from the Psychology Act would allow for recourse only through a court of law, which is time-consuming and costly.
Dr Beal: Our third issue is that psychological services provided to children by school psychologists are, for the most part, the same services provided by psychologists in health care facilities. Psychologists who work in schools provide psychological assessment and diagnosis, individual and group psychotherapy, counselling and consultative services to children and their families. They also receive preventive programs to prevent the development of mental health problems. Our referral questions cover a wide range of psychological problems which include learning disabilities and problems, behaviour problems, debilitating fears and anxieties, depression, suicidal thoughts and gestures, and social problems.
The psychological services we provide for children in schools have a profound impact on the physical and mental health, and on the educational future, of the children who are our clients, and on their parents as well. These services should be regulated by the Psychology Act and RHPA, whether they are delivered in schools or hospitals or clinics or private practice offices.
Mr Blackstock: The exclusion of psychologists in school boards from the Psychology Act could lead to the replacement of qualified psychologists in schools by unqualified teachers who are given the mandate to provide psychological services to children.
Under the current Psychologists Registration Act, psychological services can be offered only by or under the supervision of duly registered psychologists. Accordingly, the Ministry of Education has determined that psychological services may be provided in school boards only by a registered psychologist or a qualified person working under his or her supervision. Individual school boards under pressure to retain teachers where enrolments are declining may be especially anxious to replace psychologists with teachers. The act as it now reads deregulates psychologists working in schools, eliminating the requirement that school boards offer psychological services through a registered psychologist.
Under the current language in the proposed legislation, teachers could call themselves consultants in psychology, or could offer psychological services, psychological assessments and psychological diagnosis. In fact, they could call themselves psychologists, as long as they did not offer health care services, which are undefined in legislation. The public, and especially the most vulnerable segments of the public, would not be able to distinguish between registered psychologists and those unqualified consultants, or between regulated psychological services and the services provided by those consultants. The public's awareness of the nature and quality of the service being provided to them would be diminished. Public protection would likewise diminish, rather than increase.
To make it concrete and real, here are two very brief case studies of what could happen. Imagine a school board somewhere in Ontario where, for various reasons, the department of psychological services -- the people who work there -- had been replaced. These registered psychologists, regulated psychologists, are gone and they are replaced by teachers. A student comes to the school board in grade 3 from some country far away. He speaks a different language, has a very different culture, and his family is struggling to adapt to a new country. It is obvious that he needs an assessment to adjust, and to deal with learning problems that he is exhibiting. This well-motivated, well-meaning teacher, who is identified as a consultant in psychology, who is working for the department of psychological services, does an assessment and, not being trained in making differential diagnosis and all the subtleties and the difficulties in making an assessment of a culturally different person, concludes that this student is a slow learner. It goes to an IPRC committee, and the student is placed in a class for slow learners. That is a very possible scenario.
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The second scenario happens seven years later when the same student is exhibiting severe depression, emotional problems, and the family is very concerned about it and goes to the family physician. The family physician, in his or her wisdom, says, "You should see a psychologist." The family, although they are doing well, cannot afford a private psychologist because, unbelievable as it may be, psychologists are still not covered under OHIP. They have a memory of the psychological services department in the school board and they get referred to the school psychologist who, you will remember, is a teacher who has been reassigned, rather than a trained, competent and regulated psychologist.
Depression and severe emotional difficulties are often difficult to recognize and diagnose in adolescents, especially when they are culturally different adolescents. This practitioner does not catch the fact that there is a severe depression going on and that there is a very high risk for suicide, and says so, which increases the family's feeling of helplessness and hopelessness, and the child's feeling of helplessness and hopelessness, and he could end up by killing himself. That is a possible scenario under the present legislation.
Dr Beal: Our concerns centre on subsection 15(1) of the proposed Psychology Act. We have two alternative suggestions that we have outlined in our brief, and I will touch on them lightly.
Our first one is that we encourage the restriction of the title "psychologist" or any descriptor like "psychological" to persons who are registered or regulated under the act. We would see that as being less confusing to the public and providing a greater accountability of the profession, or people who allege to provide those services.
The alternative is to broaden that section of the Psychology Act so as to include psychologists who do not offer what we call health care services to individuals by dint of where they work, if they work, say, in an educational setting, to include those people under the act, to leave the profession of psychology as an intact profession and not split it in terms of regulation, in terms of where you work. Some people who practise as psychologists in school boards also provide private practice services to the public. By wearing one hat in one job and another in another, it could be quite confusing.
Dr Blackstock: I appreciate the opportunity to make the presentation and urge you to adopt some of the proposed amendments to subsection 15(1) of the Psychology Act. Thank you. We are open to questions.
Mr J. Wilson: I think you make a very good point. It has been made before about subsection 15(1). You also point out that the health profession legislation review did not recommend the phrase "providing health care to individuals," so perhaps I could ask, once again, the parliamentary assistant: How did this phrase creep, or what is the reasoning behind this phrase creeping, into the legislation?
The Chair: Mr Wessenger?
Mr Wessenger: I will ask counsel to indicate the answer to that.
Ms Bohnen: The review did not include legislative counsel or any legislative draftsman on its team. The way it proceeded was by developing the concepts, such as concepts of title protection, and then, where there was existing language or boilerplate available from other statutes, in this case basically from the Health Disciplines Act, inserting that into the recommendations.
The review was certainly aware that these recommendations, which comprised its report, would be transformed into proper statutory language by legislative counsel in the Ministry of the Attorney General. In the course of that transformation, it became apparent that there ought to be an anchor for these title provisions. Although this was legislation dealing with regulation of health professions and protection of the public when they obtain health services, there did not seem to be an appropriate anchor for the title protection. Just as, for example, the controlled acts refer to activities done in the course of providing health care services, it appeared desirable to anchor the title protection to the provision of health care, because that is where the potential for harm in misrepresentation to the public seemed to arise. That is why the phrase was inserted into the legislation.
Mr Owens: One of the issues that this committee dealt with during the session after Christmas was the issue of children's mental health services, trying to determine where the access point for these services should be. If we decide to use the school system as the point of entry for services, do you see this legislation as inhibiting that access?
Dr Blackstock: That is a good question. We very much support the notion of providing children's mental health services in the school setting for a variety of reasons. It speaks to the need for those psychologists who are identified as school psychologists, or on the staff of departments of psychological services, to be regulated psychologists -- trained, qualified psychologists rather than teachers. If teachers are permitted to call themselves psychologists or psychological consultants and, in fact, those mental health services shift to a school setting -- which we think is very appropriate -- there is, I think, a great danger that there be a temptation to provide those mental health services by the untrained, unqualified practitioners.
Mr Owens: Is this currently the practice to have teachers as psychologists or psychological consultants, or is this a scenario that you have developed to emphasize your point?
Dr Blackstock: In some cases, in some school boards, there are, in fact, people called "teacher diagnosticians" who do some of the psychological services. We were very concerned about that, because our personal experience is that awful errors get made by teacher diagnosticians who are asked to do a psychological assessment. It is happening now in a few places in the province, but not generally. Generally, the departments of psychology are peopled by registered psychologists and their associates. We are very happy with it.
Mr Beer: I would like to go back to Mr Wilson's question, if I could, to the parliamentary assistant, and I want to read subsection 15(2) in relationship to subsection 15(1). My question would be: If we took the example of somebody in a school board using the title "psychologist," although he or she was not, in fact, a member of the college, how would 15(2) apply to that person in terms of seeing that that did not happen, and affording the kind of protection that has been of concern here?
Mr Wessenger: I will ask counsel to reply to that one.
Ms Bohnen: As you point out with your question, there is still the prohibition against holding oneself out as a member of the college. That holding out can be effected in a number of different ways, including inappropriate use of a title or other indicia of what one's qualifications are.
I would just add, it is not the purpose of the title protection provisions to, let us say, restrict a school board in who it employs to provide particular services. The issue ought not to be: Amend these title provisions so that school boards cannot hire psychometrists, or teachers, to provide a service that they need to provide to their pupils. The issue ought to be only: What titles and representations can these non-psychologists be permitted to employ? Often the issues are melded. The review was aware of the fact that sometimes title issues become the forum for fights over who should be providing service. It is important to keep them separate.
I just point that out because I see in the submission that concern about school boards employing non-psychologists to provide services. That may indeed be a concern, but I do not think that it is helpful to this committee to deal with that concern in the context of title protection.
Mr J. Wilson: The concern is providing psychological services.
Ms Bohnen: There are two issues. How you describe the service and who ought to provide the service. I am just saying, let us try to keep them separate.
Mrs McLeod: Madam Chairman, just as a point of clarification relating to the information legal counsel provided the committee with in Ottawa, that nevertheless, the application of the act -- the holding out as well as the carrying out of controlled acts -- applies outside health care institutions.
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Ms Bohnen: Absolutely. The scope of practice of psychology which is the anchor for the title protection as an instance of the provision of health care, is not restricted to hospitals or traditional health care settings. Much clinical psychology clearly takes place in educational settings.
The Chair: Thank you very much for appearing before the committee today. I know you are aware that you can continue to communicate with the committee in writing at any time through our clerk.
I would now like to call the Committee for Independence in Living and Breathing. While the deputation is arranging the microphones so that they can begin their presentation, I would just point out once again to committee members that you can submit questions in writing to the ministry staff if you want to prepare for the discussions we are likely going to be having around these kinds of specific issues on September 16 and 17, and that you can, at any time over the course of the deliberations, request from the ministry staff answers to your questions in writing. Often there are members who have questions that we just do not have time to get on the Hansard during the presentation. There is the opportunity for those questions to be responded to in a number of different ways. The committee members can directly ask those questions in writing of committee staff and they are then part of the public record of our deliberations.
COMMITTEE FOR INDEPENDENCE IN LIVING AND BREATHING
Mr T. Wagner: My name is Tom Wagner. I have been a ventilator user for eight and a half years during which time I have been living in the community at my family home with a part-time attendant, and I am a student at York University.
Mr McLellan: My name is Jack McLellan. Eight years ago this Friday I dived into a swimming pool in my backyard and broke my neck. I spent two years at Sunnybrook ICU, that is the intensive care unit, where I was ventilated and I still am ventilated at night. I have spent the last six years in Whitby General Hospital in chronic care, where my colleagues' average age is about 82 years old. As a result, everything is geared to that geriatric crowd and I would sure like to get out of there.
One of the problems is because I use a ventilator, and it brings with it so many restrictions that it is almost impossible for me to get out in the community. I think I will let Margaret carry on from there.
Mrs M. Wagner: I am Margaret Wagner. Jack and I are the co-chairs of the Committee for Independence in Living and Breathing. By virtue of the name relationship, you probably guessed that I happen to be Tom's mother, which is incidental -- he is an adult, he is in charge. I am providing some care when the attendants are not there and I am also a health professional who is a strong advocate for community living and for disabled people.
Mr MacPherson: I am Steve MacPherson. I am a founding member of CILB. I too had a diving accident. I breathe with phrenic nerve pacers 24 hours a day, and just this year moved out of West Park Hospital into an attendant care support service project.
Mrs M. Wagner: Our committee is approximately one third ventilator users, closing up to 50% rapidly. All of these people are living in the community and looking for better opportunities in the community. What we are here for is to talk about barriers that we hope will not be added to and make things more difficult.
Tom and I attended the seminar on July 28 that was held to discuss this law. At the seminar we had the fortune of meeting other people who had common interests, and on the one-page summary of our brief you will see that there were quite a number of agencies involved. We met on the morning of August 9 at the Ontario Medical Association and we spent two hours drafting the one sentence which is in bold print partway down the page there. The various colleges and associations took this wording back to their associations. They are in agreement with it, and as well, the respiratory therapists, physiotherapists, occupational therapists, etc, have also been approached. They are in agreement with this wording.
The difficulty that we have rests with paragraphs 26(2)5 and 26(2)6, which talk about controlled acts, etc. So our statement is recommended as an addition to section 26, subsection (4), as I said, a separate addition to the act. We feel that limiting the performance of controlled acts to specific professional persons impacts very strongly on the rights of persons to choose who looks after them, to choose what care they are given, to choose where they live, and to generally control their own lives.
Mr McLellan: In my case I do a lot of volunteer work for various organizations. I am the spokesperson for the March of Dimes again this year, and I will be going out with a speaking bureau. While I am out I will be depending upon other March of Dimes volunteers to help me get around, opening doors and driving my van. Because I am unable to cough, I require a mechanical device, a suction kit, to clear my lungs of any mucus, so I depend on the same persons to perform that suctioning for me, after some instruction from me and under my direct supervision. This law will certainly impinge on that, and that would be a terrible restriction on me.
Mr MacPherson: What we are really concerned about is the that we do not need or want to be protected by others. We do not want our care needs defined by others, and we do not want those who give our care defined by others. But we do want control of our lives and to be self-directed. This has a profound impact on where we live, where we work, our education and recreation.
Just this summer I went up north to the family cottage area. It was a cottage that my mum had actually rented where I was looked after by family and friends. We are concerned that in the laws or in the acts or even the regulations, we may lose the ability to do just as you would do to yourself. Because we are restricted with our physical disabilities we rely on other people to help us out.
Mrs M. Wagner: I would like to read a paragraph from an article which is attached to our brief. The article was written by one of our members who is an administrative consultant at the Hugh MacMillan centre. She is a committee member and is also a ventilator user.
We have been asked many times why we are so concerned about this. We are concerned because we see what is happening elsewhere when the law, which is not intended to cause a barrier for handicapped people, ends up doing so.
This paragraph says: "Comparable professional territorialization is happening in Manitoba and in New York. A few months ago Concepts of Independence, an independent living centre attendant service in New York, which has been successfully administered for 10 years by its tracheostomized and ventilated consumers" -- I know some of these people; they are running a tight ship -- "received seven citations to cease and desist use of attendants for such procedures as catheterization, suctioning and changing trachea tubes."
We are afraid that ultimately, without the protection of the law, this could happen here. I do not believe that was the intent of what is happening, but we have seen it happen elsewhere and therefore our concerns are great. We have yet to hear from our friends what is happening as the outcome of these seven citations. They are carrying on at the moment, in spite of the citations, and they have won a couple of deferrals. But we do not know what the outcome is, and the question is, why should they go through this?
We are, I think, open for questions.
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The Chair: Thank you very much for a very important and articulate presentation before the committee. We have heard from a number of consumers of services and I think you have made the point about your desire as consumers for independence and control very well. I know that is the desire of all the members of this committee from all three caucuses.
Mr Beer: Thank you for your presentation. Steve, I am delighted to hear that all your struggles at West Park have resulted in you being on your own, as it were. I think, too, I would want to say that the work you have done with others in drafting this amendment that you are putting to us is one that we have been told was coming, and so we are very pleased to get it, and support the intent of what you are trying to do, because clearly we do want to make sure that you can live independently.
I wonder if you might, for the record, share with the committee how many people currently in Ontario require various kinds of breathing assistance to give us a better sense of the impact on that particular community?
Mrs M. Wagner: The answer is we do not know. There is a new coalition set up that will have a respiratory subdivision, and I know that one of their proposals is to do a two-year study on just this thing. We know of approximately 15 people in this area who are trying -- Jack being one of them -- to get housing that is much more amenable to independent living. As we have said, one of the biggest failures is the fear of attendant care to take over what is perceived as professional procedures and the fear of professionals to let go. I understand that fear because, as I mentioned, I am also a professional.
We are trying to gather statistics on this, as a matter of fact, but we honestly do not know because a number of them are stuck in ICUs, and they are what is commonly called a bed-blocker. They do not want to be there, the hospital does not want them there. The trick is to get them out of our hospital. So we have that group, and that is hard to get statistics on.
We also have a large number of potential ventilator users in muscular dystrophic young men, and Tom is one. We have one or two others here today who are living long lives. I do believe that 10 or 20 years of life is a worthwhile gift. We can estimate that from the statistics through the Muscular Dystrophy Association of Canada.
Another thing I feel you ought to know is that in Ontario and in Canada today people who could be ventilated are not being given that option, they are not being given the information and they are being allowed to die, partly because of other people's perception of quality of life and what is ethical. The other reason is that the people who would give that information simply do not know about it. I do not think anything upsets our committee more than to have news of other young men dying. So I cannot answer your question.
Mr Owens: I would like to thank you, along with the Chair and my colleagues, for your presentation. I especially appreciate the remarks around the situation that is occurring in New York at this time. I am always appalled and quite amazed at some of these enforcement agencies as to where they are on the cutting edge of stupidity, and these folks clearly seem to be on the leading edge.
I am just wondering what kind of response you have had from our ministry people with respect to your, I would suggest, fairly unique situation. As the Chair indicated, we have heard testimony from deputants and attendant care providers, but you have the issue around the ventilator. Have you had any type of response?
Mrs M. Wagner: We have put on a number of seminars, three to be exact, to which we have invited ministry representatives. They have come and I think they have been sympathetic.
Mr Owens: Could we ask that as a supplementary to the ministry staff?
Mr Wessenger: Yes, I will have them comment.
Mr MacPherson: The response in the Metropolitan Toronto area has been quite positive. Charles Beer would know that. Warner Clarke has been able to suggest to our groups and to other individuals: "If you are waiting for guidelines and that to change, directly there's nothing I can do, but show me why you should be in your own apartment in the community. That is the main reason I can say yes and open up some doors."
I have met with several other people in just the last months, including Bob Rae, just to make him a little more aware of the needs out there and that things are changing slowly. But we do not want to take a big step backwards either.
Ms Bohnen: I cannot comment in general on the Ministry of Health response to concerns about independent living. The current minister and her predecessors, including this Chair, have been very clear that this legislation will not be permitted to create additional obstacles to independent living for the disabled and have committed themselves to an exception for this. The only outstanding issue has been where this exception should be placed. I participated in discussions with the people who are here today, as well as some other representatives of groups, to talk about what might be appropriate language to the exception, whether it appeared in the statute or in a regulation. I know the government is not in a position to say today whether it now believes that an exception should go into the statute.
Mr Hope: Just briefly -- it is not really a question, it is a gesture -- I am also the parliamentary assistant to the Ministry of Community and Social Services, which deals with the issues. Dealing with the strategies for the deinstitutionalizing and also dealing with long-term care, rest assured that your comments have been fully briefed to the minister.
The Chair: On behalf of the committee, I would like to thank you for appearing today. I think you have, as I said before, given us a very important, well articulated understanding of the need for the shift to the kind of community-based services that are possible today because of new technology and the challenges that all legislators are facing, not just in Ontario. That will be very helpful to us in our deliberations. We have said repeatedly, and I know I am speaking for all three caucuses when I say, it is the goal of this committee to ensure that your desire for independence and control is the goal this committee will do its part in achieving in this legislation.
Mr Owens: The government would like to associate itself with those remarks as well.
The Chair: As I said, I think that is a non-partisan statement clearly from all three caucuses, all members of this committee. I would be surprised if I was considered presumptuous if I said I felt that I was speaking on behalf of all members of the Legislature.
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STEPHEN GRIEW
The Chair: I would like to call Stephen Griew. Welcome to the standing committee on social development.
Dr Griew: May I start by apologizing for not being able to get here last week. It had nothing to do with my hearing. Facetiously, if there had been a gastroenterologist on the committee, I would have chartered a helicopter to get here. I am very pleased to have this other opportunity. I shall speak very briefly, since the written submission that I put in summarizes what I want to say very well.
The Chair: It was distributed last week.
Dr Griew: My concern is with the proposal that prescription of hearing aids should be a controlled act. My written submission suggests four reasons why this should not be so. First, in my view it is unnecessary. Some say there is evidence that the present arrangements put the hearing-impaired of Ontario at risk. I know of no such evidence in this jurisdiction or elsewhere. I am convinced that my teenaged children daily face more danger to their hearing from their Walkmans than I do from my hearing aid, although I must say their Walkmans protect me from listening to the racket, so this also protects my hearing.
Second, far from protecting hearing aid wearers from unspecified and uncorroborated dangers, making the prescription of these aids a controlled act would, I believe, place the hearing-impaired at real risk, the risk of having aids prescribed that would be less than satisfactory to their needs. I elaborate on this assertion in my written submission, and I can simply summarize now by saying that I agree with many who believe that with few exceptions, clinical audiologists are simply not as good as hearing aid practitioners at prescribing hearing aids that accommodate the highly individual circumstances of the individual user.
My third concern is one that I believe has not really received sufficient exposure in this debate. This is the consequences the provision under discussion would have for the older hearing-impaired person, of which, because nature made us the way nature did, there are very large numbers. Here I speak as a professional gerontologist who has spent nearly 40 years studying aging, writing about it, working with the elderly and teaching gerontology. Again, I elaborate on this concern in my written brief. I shall simply now reiterate the main point I made there. If this provision finds its way into enacted legislation, then as sure as we are all sitting here today, it will have the effect of deterring senior citizens from seeking the relief offered by hearing aids and, if I may say so, with grievously tragic consequences for the quality of their lives.
My last concern is about cost and accessibility. Some plausible arguments have been advanced to downplay the cost implications of making the prescription of hearing aids a controlled act while at the same time maintaining accessibility. In the absence of hard facts, it is impossible to be certain of anything, but using some quite conservative assumptions, my own figuring leads me to the conclusion that the increased direct costs of providing audiological services to those who would otherwise look to hearing instrument practitioners for the services they require, would be quite high. Add to this cost the additional cost of training additional audiologists, and it could quite easily escalate into something even higher.
I am not naïve enough to think that finding this sort of money would cripple the provincial budget, but it would be money well spent if it genuinely led to a better deal for the hearing-impaired and the elderly. It seems an awful pity to spend it when, far from improving their lot, its effect would in fact make their lives more difficult. My own experience -- I mention it in my written submission -- has been that if prescription becomes a controlled act, when I next need another hearing aid, I shall take myself off to Buffalo, where I can legally obtain a prescription from a hearing instrument practitioner. My goodness, what a saving this would represent to our beleaguered health budget.
This leads me to the final point I would like to make. It is one that did not occur to me until the other night. It is this: I know of no other jurisdiction comparable with Ontario where the prescription of hearing aids is a controlled act. There are probably some; I do not know of them. Now, I do not claim to know everything about these things. As I say, there may be jurisdictions in which this restriction applies, but it does not apply in Australia, Britain and other countries in Europe I know about or in any of the states of the USA or in the provinces in Canada with which I am familiar. It may apply in the Soviet Union, though probably not for much longer in that country either. All this sharpens my concern. If it is so widely considered unnecessary elsewhere, I find it awfully difficult, really, to understand why we need it here.
There, then, are my concerns and why my ardent hope is that the provision that would make the prescription of hearing aids a controlled act will not survive into enacted legislation. Thank you. I hope I am going to be able to hear the questions.
Mr J. Wilson: I think it has been argued by audiologists that there is a risk of harm from improperly prescribed hearing aids. In your practice as a gerontologist, do you see many cases of harm caused by improperly prescribed hearing aids?
Dr Griew: I have never met one.
Mr J. Wilson: Never met one?
Mr Griew: No. I have many colleagues who have worked in this field; I have many friends who wear hearings aids. I have not yet come across a single case.
Mr White: And your patient satisfaction is high. I assume you are referring patients to hearing instrument practitioners.
Dr Griew: I should make it clear that I do not have patients. I am not a clinical gerontologist. I am a gerontologist who studies the process of aging and advises on the adaptation of various functions.
Mr J. Wilson: As a hearing aid user, obviously your testimony is that you have no problem with hearing instrument practitioners whatsoever.
Dr Griew: None at all. I would dearly like to see the evidence that some people say there is. I have not found it myself, and this is not the one to trick me.
Mr J. Wilson: Good point.
The Chair: Thank you very much for your presentation. We appreciate your presentation. We appreciate your appearing before the committee today. If there is additional information or data that you think might be helpful to committee members, please feel free to submit it to us through our clerk during the course of our deliberations. We are pleased that you were able to reschedule so that you could appear today.
The committee recessed at 1228.
AFTERNOON SITTING
The committee resumed at 1404.
ONTARIO FEDERATION OF COMMUNITY MENTAL HEALTH AND ADDICTION PROGRAMS
The Chair: I would like to call, first, Ontario Federation of Community Mental Health and Addiction Programs. Welcome.
Mr Howse: I am Greg Howse representing the board of directors of the Ontario Federation of Community Mental Health and Addiction Programs and the executive director of Simcoe Outreach Services in Barrie, which is an assessment service for people who suffer the effects of addictions.
The Ontario Federation of Community Mental Health and Addiction Programs ia an independent organization of programs funded by the Ministry of Health, the community mental health branch. The federation represents over 180 organizations, employing approximately 2,400 people who provide services to mentally ill individuals and their families and to individuals suffering the effects of drug and alcohol abuse.
The first meeting of the federation was in July 1985. There was a series of meetings of successively larger groups of agency representatives who met to share resources and explore common issues. It was discovered that the issues faced were the same regardless of the nature of the agency, its service or its location. The issues were independent of the individual manager and were in fact the issues of the service organizations and the broader system.
A provincial association of organizations was needed to represent the interests of community mental health service providers and address their systemic issues. No such association existed to represent these agencies although a relatively small number, 34 or less than 10%, were Canadian Mental Health Association branches associated with the Ontario division of the CMHA.
By 1986, the federation was a voluntary non-profit corporation with over 170 member organizations from across Ontario. This included the Ontario division of CMHA and most of the branches. As each member organization typically had more than one service program, this represented approximately 70% of all funded community mental health services in Ontario.
In the same time period, addiction services of various types were transferred into the adult community mental health branch's jurisdiction. Given that the interests and issues of the federation were systemic and related to administration and funding by the ACMH branch, the addiction programs were welcomed into the federation and the name changed to reflect this constituency.
The federation envisions a community mental health and addiction system which exists to assist and support people: to achieve their potential; to enjoy a positive and productive lifestyle, and to live, participate, and contribute in their communities.
Members of the federation support the legislation but we have two concerns. The first concern is paragraph 26(2)1 of Bill 43, the controlled act. That is: "Communicating to the individual or his or her personal representative a conclusion identifying a disease, disorder or dysfunction as the cause of symptoms of the individual..."
The Ministry of Health has created a system for addictions treatment in Ontario. The hubs of the system are assessment and referral centres and there are around 34 of them in the province today. These programs were established to assess individuals' addictions to alcohol or other drugs. As many of you are aware, there is a great debate about whether alcoholism is a disease. In fact, the Supreme Court in the United States is being asked to decide the very question. If alcoholism is not a disease, it is certainly a disorder or a dysfunction. The issue that the managers of the assessment services have here is: How do we communicate to individuals after completing an assessment if it is prohibited by this legislation?
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Similar experiences will occur in the mental health services. Treatment services for outpatient mental health in the province are staffed by social workers and other non-regulated professionals. Once again, the function of many of these staff is to relate to individuals or their representatives findings in regard to a disease, disorder or dysfunction. Some services could perhaps circumvent the law by having a psychiatrist on staff, but this is merely a way of getting around things. Staff in housing programs for psychiatric patients can and do talk to individuals about how they are functioning. If a staff person notices symptoms increasing and gives some advice to the client based on these observations, would that person be in jeopardy of prosecution because the client places a great deal of reliance on the advice of this unregulated professional?
In our working life, staff in mental health and addiction systems often relate to individuals their conclusions about disease, disorder or dysfunction. In fact, if this section is proclaimed, staff could be breaking the law and liable to fine or imprisonment. A number of individuals involved in the process indicated that there is no intent to close down existing programs. The concern, though, is what would judges think if the section was proclaimed as it is written?
Another concern of the federation was subsection 27.04 in the original drafting of the document which was presented in 1989, in other words, the harm document. The federation would like to reinforce the fact that this section has been removed and it should not be reintroduced. The harm section, as it was written, would in all likelihood create more havoc in the mental health and addictions field because the section talks about offering treatment or advice. In our business, on a daily basis, if not treat, we certainly offer advice to individuals. They do, I am sure, rely on that advice.
I would urge you then not to reintroduce the harm clause. That is my presentation.
Mr Owens: My question is for ministry staff, through the parliamentary assistant. My understanding is that, in terms of the order in which people seek treatment for their addictions, probably one of the last groups they see are physicians. They would seek out help from centres such as this first, or through a pastor or a family member. How would this legislation under the diagnosis clause impact, in the ministry's opinion, on the types of services these addiction centres would be carrying out?
Mr Wessenger: I will ask staff to elaborate on that.
Ms Bohnen: I think it is important to distinguish between the two forms of assistance. First there is an individual seeking assistance with his behaviour -- drinking too much, being addicted to a substance, be it alcohol or some other substance -- and appropriately, as you say, following the usual course of seeking assistance from non-medical people, volunteers, professional addiction counsellors and so on. We do not believe the legislation would infringe on that.
However, if an individual in addition to, or instead of, being aware of an addiction problem, suffers from physical symptoms such as -- I am not expert enough to know what some of the physical signs of addiction might be, but let's say signs of liver disease, more neurological symptoms, seizures, things like that, I think the Ministry of Health would expect an individual with those physical symptoms to seek medical assistance to determine whether the symptoms of his liver disease are related to his addiction, or if he has some other problem. In any event, those symptoms will need medical management.
This will not force people to go first and only to physicians for assistance with their addiction, but rather, yes, people will go to counsellors for addiction counselling and behavioural change and, yes, will continue to go to physicians where they also have medical problems related to their addiction.
Mr Owens: If I can ask a supplementary, how would that relate to the psychiatric problems which can stem from addictions? I am not sure where I am heading on this but I just sense there is a real problem in separating the organic or the physiological addiction from the psychological aspect of the issue.
Ms Bohnen: Remember, it is not as if this legislation were being put in place in a void. There is a functioning system that will continue to function, and I guess a minority of people will go to psychiatrists or their family physicians for help with the psychiatric symptoms of their addictions and most people will not. Most people will go to addiction counsellors, Alcoholics Anonymous and other agencies like that. That will not change.
Mr Beer: Having a better sense of what it is you are doing on a day-to-day basis, in looking at your activities today, the role you play in working with a physician, with the people who come into your centre -- I would see you are working primarily within a context where a diagnosis had been made by a psychiatrist, or in some setting such as that. While you would continue to communicate and discuss various things, in no real sense could one say you were making the diagnosis, but rather that it was an assessment, and so on. How do you work today, and can you relate that to the concerns you expressed, and its impact on you if this went through?
Mr Howse: A simple accounting which I can relate to you: We have had 800 people referred in the last year for an addiction problem, a number of them referred by family physicians, for example, who want us to determine the extent of their addiction. My concern is that I am communicating to an individual the extent of that addiction, and that is the wording in the legislation, or the proposed legislation, "communicating." It does not say "diagnosis." The old legislation maybe talked about diagnosis; this one just says "communicating a conclusion."
We, as unregulated professionals, often communicate conclusions to individuals for physicians, for example. Physicians do not have the expertise that we do in regard to alcohol and other drugs, and their psychological impact. They do not have the time to sit down. Our assessment takes upwards of three hours to complete. We are looking at not only physiological, but school or work issues; we are looking at education issues; we are looking at home life; we are looking at problems with the law.
It is a psychosocial examination, a psychosocial assessment, it is not only physiological. That is only one part of the entire spectrum of problems people get into when they become addicted to drugs or alcohol.
Mr Hope: My question, I guess, is going to be a contentious one, but I want to pose it to you. It is not only through marijuana and other things, there is also substance abuse and drug abuse through prescribed drugs. That is really going to jeopardize what is reflected in the Martin report dealing with the disabled community and the seniors. If an individual says, "I am feeling very antidepressed, or hyped up; I am addicted to something," how is that going to work with the medical model, prescribing medication and at the same time pulling the person off that medication because of the addiction aspect.
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Mr Howse: We are often dealing with individuals who have been using Valium, for example, for 20-odd years and they come to us and say, "I want to get off." The manuals that drug companies put out say, "Use it no more than two weeks." Another drug is Halcion, which is a sleeping pill. "Use no more than two weeks," and people have been on it for years. They come to us and they say, "I do not want to be on this medication any more." We have to get the doctor on side, and it is usually not a problem. It effectively begins a process, in conjunction with physicians, of weaning people off these medications that may not be necessary. We find it an awful lot as well in the psychiatric client who is taking multitudes of drugs. People are taking drugs to combat symptoms of the drug they are taking for their psychosis, for example.
There is a number of reports, especially with women who are prescribed antidepressants -- women are not necessarily depressed -- and not only antidepressants but Valium and Librium as well. Women are coming to us and saying, "Look, I want to operate in society without these drugs. Can you help?" As I say, we talk to the physician, or the patient will talk to the physician and say, "Look, I am working with Simcoe Outreach Services, and I want to get off these drugs." They are usually quite co-operative.
Mr Hope: Your diagnosis refers to the drug that is causing the symptoms that the individual has?
Mr Howse: Yes.
The Chair: Thank you very much for your presentation before the committee today. I have told most of the deputations that if you think of anything over the course of our deliberations that you feel might be helpful, or any information that you receive, please feel free to communicate with us in writing through our clerk.
LABOURERS LOCAL 183 MEMBERS' BENEFIT FUND
The Chair: I would now like to call Mr Murray Gold of the Labourers Local 183 Members' Benefit Fund.
Mr Gold: The 183 Members' Benefit Fund is a multi-employer, jointly trusteed, labour-management health and welfare fund, one that delivers a variety of health and welfare benefits to members of the Labourers' International Union of North America, Local 183.
In 1979 it established a dental clinic as one means to deliver dental services in the most cost-effective, yet high-quality mode they could design. At this point, the clinic is a substantial consumer of dental services. We are looking at about 15,000 patients a year who receive dental services in a manner that is suitable for them, in their own languages, and hours that are suitable to them, through a staff that comprises qualified professional practitioners including a dental administrator, 13 dentists, three dental hygienists, 19 dental assistants and six receptionists and other clerical staff.
The clinic itself delivers most dental services at its own premises at 1136 Dupont Street -- all the basic services. It maintains relationships with outside professionals for specialized services, people like orthodontists and periodontists.
The clinic, to our knowledge, is a unique institution in Ontario, being a creature of the collective bargaining process, having participation from both labour and management, and delivering services as a large organized consumer of these professional dental services. In this way, it is able to obtain dental services at preferred rates because it offers practitioners a very steady workload, and does not compromise at all on the quality of delivery. Since it is a non-profit organization, the full benefit of those economies are passed on to the members.
The perspective that we bring today is that of a large consumer of dental services, and we would just like to go over three areas where we have encountered some concern, and to draw those to your attention, particularly how the legislation would influence those areas.
First of all, with respect to dental hygienists: Until the onset of this recession, the clinic experienced a chronic shortage of dental hygienists. We were simply not able to hire the number of dental hygienists we needed. As a consequence, dentists were hired to perform basic work, cleaning and scaling and conducting preliminary examinations that could easily have been performed by dental hygienists at a much lower cost. The recession has eased this supply crunch, but our fear is that it is temporary and once the recession lifts we will again be confronted with a shortage of hygienists.
So we look to this legislation to see whether it puts in place institutions, rules and procedures that will allow the system to produce an adequate supply of dental hygienists. Our experience has been that the existing system for regulating supply is not adequate, and when we look at the new legislation we see a potential role for the advisory council. We see that its role as an independent third party in the health care process should be greatly enhanced. It should be given a much more directed consumer protection mandate. Certainly one of the things we think they should be doing is monitoring the supply of health care professionals. This arises directly out of our concern and our experience with dental hygienists, but I am sure the observation can be applied more broadly.
We would anticipate that, in reaching conclusions with respect to supply, the advisory council could consult with organizations such as our own and with others so policy-makers have a much firmer sense of where shortages are and what can be done about them.
With respect to dentists, we have had one major concern develop over the past years. That relates to the necessity for us to compensate dentists on a fee-for-service basis. The reason we are compelled to pay a fee for service rather than to employ dentists on a salary basis is because of the rules of professional conduct adopted by the Royal College of Dental Surgeons of Ontario. They stipulate that it is professional misconduct for a dentist to be employed by an organization other than a government or a government agency or alternatively by a dentist. So we as a private clinic cannot employ dentists; we must engage them only on a fee-for-service basis and that has proved to be extremely expensive.
When we look at the Health Professions Procedural Code, we see in section 90 that the councils regulating the various health care professions are still empowered to pass bylaws governing codes of ethics, that there is no requirement for prior ministerial approval, nor is there a requirement for the Lieutenant Governor in Council to approve the amendment pertaining to code of ethics until after it has been passed.
We would suggest this is not appropriate and because measures contained in codes of ethics can be used to restrict supply or influence fee schedules, protect fee arrangements, any regulations pertaining to codes of professional ethics should be made only under section 91 of the Health Professions Procedural Code. If that change were made, then each such amendment would have to receive prior ministerial approval and would also require the approval of the Lieutenant Governor in Council before becoming effective. We see this as a very important issue.
Finally, with respect to dental specialists, the biggest issue we have encountered, the most significant one, is cost. We do not supply orthodontal and periodontal services directly, but we have relationships with outside contractors, with outside professionals, and we know through our experience this has been very expensive for them and that most consumers of dental services cannot afford to retain orthodontists and periodontists. The reasons for the expense in this area may be several and may relate to the shortage of training spaces that are funded or the costs of specialized education after one goes through the dental program. We do not pretend the problem has a simple solution, but we do say it is a very serious one because orthodontal and periodontal specialist services are not accessible to a great number of people because of the cost of those services.
Once again we would urge a much stronger role for the advisory council in this area, a much stronger consumer protection role that would empower and mandate the council to investigate and develop recommendations to make these specialist services more accessible to ordinary consumers.
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Our conclusions, our recommendations, are simple. We would urge that the advisory council's mandate under section 11 be expanded so that it has an express consumer protection mandate to promote consumer access to private health care at affordable prices, to monitor the supply of, and demand for health care professionals, to make recommendations to the minister with respect to such regulatory educational funding changes as may be required in order to meet consumer demand at affordable prices, and to review the impact of technological change on the appropriate division of responsibilities between health care professionals such as hygienists and dentists, for example.
We would also recommend that councils not be able to pass bylaws with respect to professional ethical standards without prior ministerial approval, and that the power to pass such regulations be transferred from section 90 of the code to section 91 so that prior ministerial approval and approval by the Lieutenant Governor in Council will be required prior to the amendment being effective.
Mr Wessenger: I think we can give you some clarification on some of the points you raised. I am going to ask legislative counsel to do that now.
Ms Bohnen: This concerns the point you raised about the prohibition in the dental regulation forbidding dentists to work as employees of most agencies. In fact that prohibition appears in the definition of professional misconduct, not in a code of ethics. Under this legislation, as under the Health Disciplines Act, it is a regulation that the minister must give prior review to and must be approved by the Lieutenant Governor in Council. Once this legislation is in place, all of these regulations will eventually be reviewed by the Health Professions Regulatory Advisory Council in any event: so it may be that your concern that they get public government scrutiny and review will be achieved that way.
Mr Gold: I did not appreciate that. Thank you for that clarification.
The Chair: If there is any additional information you have that you think would be helpful to committee members, we would appreciate it if you would communicate with us in writing. Thank you.
CANADIAN SOCIETY FOR ENVIRONMENTAL MEDICINE
The Chair: I would like to call the Canadian Society for Environmental Medicine.
Dr Krop: I am Dr Jozef Krop, representing the Canadian Society for Environmental Medicine as their secretary and advocate, together with Dr Phillip Bright, treasurer. Briefly, the purpose of our society, set out in more detail in appendix B to this submission, is to promote the good health and wellbeing of the people of Ontario through the improvement of the environment in which they live, and through promotion of public understanding and awareness of the effect of the environment on the state of human health.
Specifically, we are advocating today the inclusion of the following clause which is modelled on recently introduced legislation in the state of Alaska, namely:
"No disciplinary body of any college constituted under the RHPA, as a regulatory body, may base a finding of professional incompetence or negligence or failure to maintain the standards of the profession, solely on the basis that a registrant's practice is experimental or unconventional, in the absence of demonstrable physical harm to a patient."
Other jurisdictions have also recently enacted similar legislation. Samples of analogous legislation are appended hereto in appendix A. Other states, such as California, Texas, New York and New Jersey are in the process of preparing similar legislation.
Our rationale for inclusion of this clause is consistent with the principles of freedom of choice and freedom to be innovative inherent in the tradition of western society. Both patient and doctor should have access to treatment modalities judged on their efficacy, not on whether they fit current dogma. We are aware that the present government, like the physician members of our society, is concerned about four aspects of health care: first, enhancement of quality of care; second, enhanced protection of the public; third, increased attention to the role of environmental factors in health, and fourth, improved cost-benefit ratio in health care delivery.
These are high priorities and intimately interwoven with our core objectives as a society and as individual practitioners. We believe they are also parts of the agenda that are accorded a high priority with the present government, as well as the opposition parties. We will demonstrate briefly below, in terms of the scientific literature and other monographs available, how we believe that inclusion of the above proposed clauses can be beneficial in achieving these objectives.
The first would be enhancement of the quality of care. Appropriate concern for, and working knowledge of, the principles of environmental medicine are present in the government. In 1984, in response to growing public concern about hypersensitivity of some individuals to environmental exposures, the Ontario Ministry of Health established a committee to study environmental hypersensitivity disorder, chaired by Judge George Thomson, the present Deputy Minister of Labour and the principal author of its report published in 1985. It is attached in appendix C. Since its publication, the working operational definition of the syndrome known as environmental hypersensitivity syndrome, found on page 17 of the report, has become a standard, comprehensible to the lay person, sufficiently precise for the professional, and cited repeatedly in subsequent reports and texts as the authoritative definition.
The committee's chapter on professional debate, page 266, indicated their increasing dismay "at the polarized and adversarial positions being taken in the United States on the issue" and unease at increasing realization "that the same hardening of attitude is taking place in Ontario." They also believed that "confidence in the health care system is eroded when productive dialogue between different medical specialists disappears, or is replaced by acrimonious debate before a confused public."
One way out of this dilemma is through the inclusion of the clause referred to above, which could provide an atmosphere of openness and sharing of information among health practitioners from different backgrounds, training and practice profiles. It would eliminate the fear of practitioners to explore new modalities of treatment.
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A correct understanding of environmental hypersensitivity disorder would eliminate the unnecessary stigma of psychiatric or psychosomatic diagnosis attached to those suffering the disorder. With further understanding and education, the medical profession, company doctors, and WCB physicians would be able to recognize the valid grounds that environmentally sensitive patients have for collecting disability pensions. Similarly, secondary insurance carriers would recognize the necessity to reimburse appropriate therapists.
The Ministry of Health could continue to be a leader in funding research, interdisciplinary conferences and education efforts. The salient distinctions between belief systems and approaches of environmental medicine and other medical approaches is summarized on page 22 of Ashford and Miller's book, Chemical Exposures: Low Levels, High Stakes, based on their report to the New Jersey State Department of Health in 1989, the whole of which is attached hereto as appendix D.
Implementation of their recommendation in chapter 6, page 147, would, we believe, result in a higher level of protection of the public. That brings us to our next heading, which is "Enhanced Protection of the Public." The biggest single issue under this heading is freedom of choice by patients to select the practitioner of their choice. Our responsibility, in participating each in his or her own way in this legislative process, is to frame legislation in which all models and aspects of diagnosis and treatment are presented to the patient so that he or she can make informed choices.
The model used by environmental physicians is to involve the patient in the process of diagnosis and choice of treatment as much as possible, and to empower him or her to participate as the partner in the healing process. Our model is not paternalistic or authoritarian. Each individual has multiple variables influencing his or her health. It is advantageous for the patient to assist in formulating the plan of care so that commitment can be made to following through in improving the level of health. This is the basis for preventive medicine.
We know today that approximately 20% of patients seek complementary or non-allopathic healing methods, such as acupuncture, homoeopathy and nutritional therapy. If physicians felt free to learn about other modes of therapy, some worthwhile and complementary techniques could be developed. Such treatment could be administered -- or at least monitored -- by the licensed physician with a special interest in these areas to avoid risk of harm to the patient.
Protection of the public implies protecting the rights of the physician in any of the medical disciplines to investigate and initiate new ideas and modalities of diagnosis or treatment in order to improve the quality of health of his or her patient, without fear of censure by colleagues. The inclusion of the proposed clause may also encourage physician interest groups to call on the College of Physicians and Surgeons of Ontario to assist in developing and disseminating helpful guidelines for practice in the new or difficult areas of medicine.
This leads us to the third aspect of health care, which is increased attention to the role of environmental factors in health. We are sure that this committee is aware of growing evidence that environmental pollution affects not only the health of the trees and other animal species, but of humans as well. From the ozone holes to acid rain to organophosphate pesticides to toxic dumping to the sick-building syndrome and electromagnetic radiation, there is an overwhelming link between our polluted environment and the increase in chronic debilitating disease leading to lower productivity, poor quality of life and skyrocketing health care costs. Some material from the World Commission on Environment and Development relating to this is appended as appendix G.
Indeed, the former minister, and chairperson of this very committee, Mrs Elinor Caplan, said, and I quote, "Unlike the contagious diseases of old, the major health threats our society faces are largely attributable to environmental and lifestyle concerns." Doctors' offices are filled with patients complaining of chronic fatigue, insomnia, memory disorders, difficulties in concentration in certain environments, chronic depressions, muscle and joint aches, gastro-intestinal disorders, etc. Greater recognition has been given to the role of environmental factors in recent years.
In addition to the previously mentioned report of Thomson's committee, there is also a Survey of the Medical Impact on Environmentally Sensitive People of a Change in Habitat, by Dr Barron, in 1990, as research for the Canada Mortgage and Housing Corp., appended hereto as appendix E, as well as a January 1991 report of the proceedings of the Environmental Sensitivities Workshop, a publication of Health and Welfare Canada, which is appended as appendix F.
Every major employer and educational institution in Ontario could benefit from the knowledge gathered by researchers and practitioners of environmental medicine. Inclusion of the proposed clause would free all regulated practitioners to learn about the environmental impact on health, exchange ideas and information, and implement effective and available treatment modalities in their practices.
The last aspect of health care with which every Ontarian is concerned is improved cost-benefit ratio in health delivery. Prescriptions, genetic engineering and more transplants will not solve the underlying causes either to our health disorders or health budget problems. An ounce of prevention is still worth more than a pound of cure. While much cost-benefit research dwells exclusively on the fiscal consequences of different health care delivery plans, we are concerned also that the social and health benefits to the patients are increased.
Environmental physicians emphasize the uniqueness of each patient. We begin with a detailed environmental history of the patient which is often sufficient to discover the cause of ailment and reduce the need for costly and potentially dangerous X-rays and tests, not to mention treatments. We counsel patients in a healthier lifestyle and diet, indicating ways to clean their immediate environment at home and seek co-operation in an environmental assessment at the workplace or school to determine and reduce the total toxic load, including such factors as electromagnetic radiation, moulds, air, water and noise pollution, to make these places safer, healthier and more productive.
We are also put in the position of having to act as patient advocates to assist in obtaining reimbursements for out-of-the-country treatment and/or other social benefits which are routinely available to patients using conventional treatments. Our time and expertise, as well as public money, could be better spent by incorporating the principles of environmental medicine to the disciplines of community health centres and setting up an environmental health unit in Ontario so that patients who are acutely sensitive do not need to travel to the United States or England for specialized treatment.
The cost-effectiveness of employing environmental medicine is staggering. Studies in appendix H show that the two goals of lower costs and increased benefits can be harmoniously and simultaneously achieved. We feel that inclusion of the proposed clause would improve a multilevelled and multidisciplined approach to helping patients lead fuller lives, which is in total harmony with the recently published report of the Premier's Council on Health Strategy.
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In conclusion, we heartily underline all of the recommendations in the eight appendices attached to this submission, drawing them to your attention in this format and recommending them again. We feel that inclusion of the clause as set out in the preamble and handout will be a concrete step in achieving the best health care for Ontarians. It will free every responsible health practitioner and informed patient to seek the treatment model best suited to individual patient needs. Madam Chairperson, this is our conclusion and we invite any questions.
The Chair: Thank you very much for your presentation. We appreciate you coming before the committee today. A very thoughtful brief. If you have any additional information, I know that you will feel free to submit it to the committee.
Mr Jackson: I notice you acknowledge the jurisdiction of Alaska as having recognized the unique nature of environmental health concerns. Are there any other jurisdictions that you can reference? I have not had the opportunity to go through, but if you could just for the record indicate those.
Dr Krop: Exactly the same legislation was put through in the state of Washington. Excerpts from it are in appendix A. To my information, New Jersey, New York, Texas and California are looking to do the same thing.
Mr Jackson: Any off-continent, to your knowledge?
Dr Krop: No, but there is one different approach to this problem. I am from eastern Europe and there, as a medical practitioner, I was free to implement any type of therapy, as long as that therapy did not harm the patient. I think it would be very important if this country had the same type of system.
Dr Bright: This is probably true in Britain, where complementary systems do work hand in hand. For example, in the national health care system there are not only allopathic hospitals but also homoeopathic hospitals and they function side by side. In fact, the royal family is a great supporter of homoeopathic techniques and treatments. I think basically there may be a slightly more enlightened atmosphere in Europe than there is at this time in North America and Canada.
Mr Jackson: I am familiar with the Yugoslavian health care system. That is an obscure story, but I am quite familiar with their interrelationship and some of the work they have done in this area. I just wondered if they were moving to a more regulatory model or if it is simply the success of certain modalities and their ability to work side by side with "more traditional forms of medicine."
Dr Krop: I am not aware of all these things. But recently I was involved in an environmental conference which was organized from here in Canada, with some participants from the United States and Japan, and took place in Poland. They at the present time are looking into the creation of a department of environmental medicine in their medical school, since they recognize the great impact of pollution on the health of the people. We have been very welcome there because we gave them a different understanding of the problems. They are looking mostly at toxicity. We here are looking from the point of view of toxicity and sensitivity, they did not realize yet, but I think it will come.
Mr Jackson: For the record, I want to indicate that the Halton Board of Education was the first school board in Ontario to develop an environmentally sensitive teaching environment, and it is very successful. It is very expensive, but it is very successful in allowing children in Halton region, and other children who are brought in, to experience their education without illnesses. So we are moving towards that.
The Chair: Thank you very much, Mr Jackson.
Mr Jackson: Thank you. I knew you were interested.
COLON THERAPISTS ASSOCIATION OF ONTARIO
The Chair: I would like to call next the Colon Therapists Association of Ontario.
Ms Towns: I am Barbara Towns. I am a registered nurse and a colon therapist. I represent the Colon Therapists Association of Ontario. Colon therapy is a topic that is often difficult to talk about. People do not like to talk about having bowel movements, but this is what this treatment is about. We colon therapists do cleansing of the large intestine. It may make some people feel uncomfortable to have this conversation, but it is necessary.
There are about 500 colon therapists in Canada, about 150 in Ontario. I have been a colon therapist for 10 years. I have seen thousands of patients. There is a great concern being brought to our attention from the patients themselves that it may come to pass, in the very near future, that they may not be able to get the therapy they want and need unless it is ordered by a physician.
The last time I spoke before this committee -- not this whole committee but some of the people here -- I brought forth the idea that most medical doctors do not know much about colon therapy. They do not know how it is performed. They do not know why it is done or why patients get a colonic. But across the board, because it is an alternative therapy, they pretty much say that it is not beneficial and advise their patients against it. In effect, if it comes to pass that a patient will only be able to get a colonic if a physician orders it, basically they are not going to be able to get a colonic.
There are several concerns we have and I could understand that a body such as this would have them. It is an invasive therapy in some ways. We use water that is introduced into the bowel, very gently, but it is done at this point in time by a variety of different people. I am an RN. Some colon therapists are registered nurses. There are laypeople doing colonic irrigations at this time.
We have appealed to the Ministry of Health to be recognized and regulated. We have not had much satisfaction in that line. We feel this is important. This is a safe treatment, as many treatments are, when it is done properly, when there is proper surgical sterilization, when the technique is done in a gentle and judicious manner. Any treatment is detrimental if it is not done properly; so part of what this paper you are now getting has attempted to do is to put forth how we believe this treatment can be conducted in a safe manner.
Mr Basen: May I interject here? My name is Lionel Basen. We have met Mrs Caplan and Linda. I am the chairman of this group, the Natural Therapies and Products Coalition. We represent a number of groups, the colon therapists being one of them. They are the one we are the most concerned about, because the new legislation is going to put this therapy, which has been around some 3,500 years -- this is not a new whacko type of money-making venture; it has been around for 3,500 years. It was practised by the medical profession up to something like 40 to 45 years ago; it was practised at St Michael's Hospital. It has not been proven to be a bad treatment; it is just not the type of treatment the average medical doctor today feels comfortable with. He would much prefer to give tablets and do surgery and the up-to-date types of treatment, as opposed to suggesting that you get a super-duper enema, which in effect is what this is. It is certainly more than that -- it is washing of the complete colon.
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The presentation you have in front of you explains the -- I was going to say the ins and the outs but -- general therapy. We are very concerned that if the legislation goes through as suggested, the medical profession will have, again, complete control of a situation they do not believe in, much like osteopathy and many other things that over the years they have taken control over. And it will die in its legal form. It will not stop it; it will still take place, just as abortions take place. We are talking about something certainly much removed from that, but it would be the same situation. It would go underground. It would still be there; it just would not be controlled. It would not in any way be regulated, and we are very concerned about that.
What we are looking for is an exemption, just as you have exempted acupuncture, or are in the process of exempting acupunture. We certainly would look to having some form of regulation in the future. We would like to enter into negotiation with the ministry because we feel that anything that is taken by the general public requires some control. However, this is not control; this is wiping it out. The users of this therapy have a very real fear that it is going to become illegal.
Ms Towns: I am a simple colon therapist. I am a nurse. I love my work. I do this every single day. I have been doing it for 10 years. It is the most rewarding work that I have ever done. This is why I became a nurse. This is preventive medicine. I spend most of my day helping people learn how to eat properly and eliminate properly.
If it comes to pass that only a physician can order this, many people who go to their physicians with simple problems like gas or because they have a bowel movement only once a week, when they go their physicians, usually the doctor will tell them to take Metamucil or to eat more fiber, and that is it. He sends them on their way. A lot of people that I have coming in to see me, say: "Now what do I do? I still can't go. I don't want to take laxatives. I don't want to get dependent on enemas." And this is very different.
There is a distinction between an enema and a colonic. With an enema, you fill up with a large amount of water and you retain that water for a period of time, generally 5, 10, 15 minutes. That stretches the bowel wall and if you do this over a prolonged period of time, the elasticity of the wall may become damaged, so that people can actually become dependent on enemas. Perfectly honestly, if a colonic was done in an injudicious manner over a long period of time, a very long treatment, possibly a person could become addicted to a colonic as well, and only be able to have a bowel movement after colonic. That is not proper technique. When it is done properly, a colonic is actually a wash. The water flows in and the water flows out, and it carries the waste away. It actually stimulates the wall of the bowel.
I am going to give you a few examples. I hope you are not completely grossed out by this, but I have an older woman who came to me, and who for 40 years had been constipated. She had been to her doctor and he told her to take laxatives and Metamucil. She tried everything, and she was still constipated, some days better, some days not so good. After three treatments, she came back and said, "This is it?" She is going every single day. Three measly little treatments. Now, that was not only the colonic. I also talked to her about simple things, eating, drinking water, having some salad and getting the bowel cleaned out enough so she could have regular movements. I have not seen her in months. She came back one time -- this was several years ago -- and said, "I went out and did some things, ate cheese and so on," and she got constipated again and went on her merry way again. This woman said: "I suffered for 40 years; I didn't have to. Why didn't someone else ever tell me this, after all the complaints I have had and gone to doctors?"
If the physicians would only listen to their patients. Being a nurse, this is adjunctive to and a part of medical treatment as far as I am concerned, but it does not have to be exclusive to medical treatment. I think that is the point. The Canadian public should be able to decide to some degree what types of treatments they need and want. They should not have to have a Big Brother doctor telling them it is okay for them to get a colonic irrigation. I think a lot of the patients I have spoken to find that personally insulting and degrading.
Mr Johnson: I find this presentation particularly interesting. In fact, the whole process of these hearings has been particularly interesting and most educational. I did not know anything about colonic hydrotherapy until I heard it today. I certainly am aware of what enemas are and I know they have been around for a long time as well.
You mention a very important fact, that personal health education is very important. I do not want to misinterpret this, but it sounds like this could be, rather than preventive, more an answer to a problem, but that may not be so.
I am curious to know how many people -- because I have never heard of this before; None of my colleagues or friends say, "Boy, I had a great colonic therapy today" -- I was wondering how widespread is this knowledge and how frequent; you said 150 in Ontario, but where is this practised most widely?
Ms Towns: Toronto. In Ontario, the bigger communities certainly have the greater population. I have been doing this for 10 years in Toronto. I see on average around 60 patients a week, maybe 70. Now this is turnover, this is not --
Mr Johnson: They are not repeats.
Ms Towns: No, they may come for one, two or three treatments and then they are on their merry way. So there is quite a large turnover of people. This is not something that is discussed a lot. People wait until they know somebody really well before they tell them. You may know people who have had colonics, they just have not told you that they have had them.
Mr Johnson: It is not something you discuss around the dinner table.
Ms Towns: No, but it does make people feel really good.
Mr Jackson: I am familiar with the procedure and I was anxious to know the basis of your referrals, since the primary concern here is the referral base and the limitations on referrals. Give us a quick run-down of where you get your referrals now and how much of that is medically referred.
Ms Towns: The referral generally is word of mouth. We do not advertise. When I started working at the clinic we put one flyer out saying we had opened, that was it. Everything else has been one person telling another person. In the 10 years I have been working I have had maybe three referrals from a doctor. One was a man who had a barium enema. They found a mass in the barium enema; they could not get the barium to go in. The man was familiar with colonics and asked his physician if it would be okay, before they did surgery, which was what they were recommending, if he could have a series of colonics and then have another barium enema. That was one of the referrals. The man did not have a tumour, it was merely impaction. His next barium enema was completely clear. The man did not have to have surgery.
Mr Jackson: I am familiar with some of these stories and I wonder whom you have talked to in terms of this legislation, officially, from the government and what feedback have you gotten on the subject. Whom have you approached and what have they said?
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Ms Towns: The only other meeting we have had was in 1989 with the Ministry of Health.
Mr Basen: Mrs Caplan was there and Linda Bohnen and a variety of other people from the ministry, and Alan Burrows. We had explained the situation and, as you are probably aware, there was a lot of reluctance to change many parts of this legislation. There was a catch-all phrase in there that virtually made anything other than the 24 groups illegal. That catch-all phrase has been dropped. I do not think it was intentional. I understood the reason it was in there, but unfortunately the ministry did not realize when it put it, in the extent of the damage it could do.
We understand the reluctance to have some sort of exemption for colonic therapy. It is not wrong to have regulation for it, but to wipe it out is another story. We would like exemption for a time and we would like very much to sit down with the ministry and work out some area where it makes it as safe a situation as it can be. Giving aspirin is not a safe situation; giving herbs in the health food store is not a safe situation. There is some risk with virtually anything you do. There is not a lot of risk with colonics.
Mrs McLeod: I will ask two very brief questions. First of all, would you be able to tell me specifically which controlled acts prohibit your practice independently?
Mr Basen: The medical act.
Mrs McLeod: But there are a number of specifically controlled acts under the --
Mr Basen: Any invasive procedure, anything beyond the anal verge.
Mrs McLeod: I was quickly trying to read through the brief you have presented. You have indicated a number of areas in which colonic hydrotherapy would be indicated and a number of others in which it would be indicated under prescription and direct supervision, as well as contraindications. I wonder if you could say a word about how you can make decisions whether it is indicated only with supervision or whether it is not indicated at all without full diagnostic procedures.
Ms Towns: The majority of people who come for a colonic generally come because they are constipated. People who come with some type of bowel disorder, colitis, Crohn's disease, they usually have been to a physician already and have been diagnosed. Those people would definitely be sent back to their physician to have the physician okay that treatment.
Generally it has been my experience that people who are having severe bowel problems do not come to us first. They seek help from their physicians. Certainly we would never do a colonic on someone who has had bleeding or who had severe pain. I think it would be a judgement that would be made by the therapist, hopefully a therapist who is properly educated and has a sense of the severity of the situation. Generally, the way they are taught is that when in doubt, just do not do it.
The Chair: Thank you very much for your presentation before the committee today. I know you are aware that if there is additional information you would like to present to the committee you can do so in writing through the course of our deliberations.
ATTENDANT CARE ACTION COALITION PLUS
The Chair: I would like to call now Attendant Care Action Coalition Plus. Please introduce yourselves to the committee. I am aware that you have some written material that will be submitted following your presentation.
Mr Parker: My name is Ian Parker and I am a consumer of attendant services. Before I refer to the few pages of my paper, I want to say that I was injured in a diving accident in 1974. I dived into a lake and hit the bottom of a beach. I spent a year, which is typical -- or maybe on the short side, actually -- in hospitals and in rehabilitation hospital. Since 1975 I have lived in the community and fairly independently as well, receiving and organizing attendants to do things for me that I cannot physically do with my own hands, since I do not have good use of my hands. By the way, were I injured just slightly farther down in my back rather than my neck, I would still be requiring some of the kinds of procedures that I use, yet I would have good hands and be able to do them for myself. So I have an attendant who acts as my hands for me.
I worked for the Ontario government, for a few years and especially in 1981, the international year of disabled persons. That is 10 years ago now and I invented the slogan, "Label Us Able" at that time, which was the slogan for the whole government to show how able disabled people really are. I do not want to be sensational, but I fear that if the bill goes through it might in some ways leave us saying, "Label us sick" and I think that would be a really unfortunate and unintentional achievement of the bill.
I am here on behalf of the Attendant Care Action Coalition Plus. We are a coalition of consumers of attendant services and supporting organizations across Ontario who want to bring about improvements and new options in attendant care services or attendant services for persons with physical disabilities. We want our attendant services. My colleague, Hazel Self, is handing out copies of my paper. I will continue.
Attendant services, as I said, are essentially what people do for me, acting as my own hands and legs. In our case, the responsibility for what is done lies with us, the consumers. The onus regarding how things are done, when they are done and whether they are done to my satisfaction and to the quality I need, rests with me. It does not rest with anybody else or any organization which may help organize the services I use.
By the way, both Hazel and I are on the board of directors of an organization which arranges attendant services, so we see the issue from many sides. We see the issues from the side of consumers as well as organizers and the people who are legally responsible for such services.
Why are we here? Well, it is the perception of many of our members and related organizations that Bill 43, the Regulated Health Professions Act as currently worded, appears to intrude on some common and long-standing practices in attendant services, and they are indeed long-standing. People have had attendant services at least since the end of the Second World War and they have been publicly funded in Ontario at least since the mid-1970s.
There is a perception that Bill 43 appears to apply to attendant services. The bill is perceived, rightly or wrongly, by general readers to do two things: (1) to define putting an instrument, hand or finger beyond bodily orifices as controlled acts, and (2) to place a restriction on those acts that they may be performed only by authorized health professionals. That in fact is not the intention of the bill. The general reader does not see that this definition and restriction of controlled acts applies only in the course of providing health care, so there is the distinction: health services, attendant services.
The people involved with attendant services, whether consumers, attendants, managers, board members or insurance companies, will generally be led to believe that the bill is making these acts illegal for attendants to perform.
There is at present no clarification to the contrary in the bill. For example, it is not explicit that certain acts in the course of providing attendant services, not being health care, would therefore be exempted. Indeed, there is no definition of health care in the bill anyway, so confusion naturally arises about the limits of its scope.
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The bill identifies certain procedures as controlled acts in health care, but it should be spelled out that these very same procedures are carried out in attendant services as -- and this is important -- routine practices with a history of government policy and government funding. There would be a real danger if these acts, through silence in the bill, were generally misunderstood to be medical or health care acts alone. Further, it would be a disaster if these acts were then made illegal in attendant services.
It is unfortunate that a lack of clarity about the limits of health care is involved here, because it is an issue that hits too close to home for people who have disabilities -- I am on page 3 if you wish to look, the last paragraph -- and where, after all the public education campaigns, there still exists confusion about our health status in the minds of the general public. It is not known widely enough that many disabled people have for a long time lived very independently of medical systems and institutionalized services, and we want to remain independent and in control of our own services.
Disabled persons living in the community are neither sick nor do we wish to be perceived as such, and this act gives the perception of such. That is why it is a danger to us. The routines we as individuals perform daily or have assistance to perform, are routine activities of living for us. We do not want them to be defined as medical acts or controlled acts or health care.
What controlled acts are involved in attendant services? Well, the procedures we are talking about here include, for example, going to the toilet and urination. Going to toilet by suppositories or enemas or other methods, using a catheter for urination, maintaining assisted breathing or even things like inserting a tampon. Some people simply cannot do it for themselves. These are the kinds of things that are totally routine within the daily lives of many people who have disabilities.
There is quite a spinoff already to the confusion which exists. It is happening already that, in new organizations or where medical people have a say in management or on the boards of these organizations, they now believe it is illegal to provide attendants for bowel and bladder care. They believe their insurance will not cover them. Confusion is currently causing some organizations, especially in the north, to deny consumers routine bowel and bladder assistance, or to set up their services in such a way that they do not provide that. This causes, of course, stress and inflexibility to the consumer. It really makes their lifestyle dependent on somebody else rather than having the same person get them dressed who would help them on the toilet or help make their lunch. If you have to wait around for somebody else to come in and do something, it causes a lot of problems and also causes the inflexibility of having to wait for some so-called professional person, whereas if it is an attendant whom we train ourselves, they are much more available to us to suit our own lifestyles. It could also put attendants out of work and cause considerable expense to the public purse.
While we wish to see an amendment in the bill, we have been promised regulation, but we do not feel that is sufficient. The bill, after all, is the first and last reading many people around attendant services will do. It is imperative that the bill be clear. It would be grossly unjust in the bill to define as illegal what disabled people have for years done daily. Regulation would require consultation and discussion all over again. Regulation does not give us protection from the minister's pen, any changes could be made in the future. It is just not fair to make it appear these are medical acts where in the past they were not medical acts.
Who supports our amendment? We have a long list here. ACAC Plus drafted it together with the Ontario Medical Association, the College of Nurses of Ontario, the Centre for Independent Living in Toronto, the Advocacy Resource Centre for the Handicapped, the Committee for Independence in Living and Breathing, and a representative from the Ministry of Community and Social Services. In addition, it is endorsed by the Registered Nurses' Association of Ontario, the Ontario Physiotherapy Association, the Ontario Society of Occupational Therapists, Cheshire Homes Foundation, the Clarendon Foundation, whom you heard yesterday, Three Trilliums Community Place, whom you have heard. It is also endorsed, I am quite sure, by most other organizations involved with attendant services. Our amendment is listed at the top of the next page.
Subsection 26(4): "An act by a person which comes within paragraph 5 or 6 of subsection (2) is not a contravention of subsection (1) if the act is done in the course of providing for a person physical assistance with routine activities of living which the person would otherwise do if the person were able to do so."
Why is the amendment in the public interest? It would correct the confusion which unintentionally is now created. It would recognize the important role that consumers attach to attendant services. Attendant services work as they are. The quality of service is good because it is tailored by the individual to meet his or her own individual needs. The consumer is satisfied with questions of health safety, and, as I have said, we would be severely limited otherwise. The cost to the taxpayer of any other system would far outweigh what we have now. Hazel, would you say a few words?
Miss Self: I have been using the attendant services for 12 years. I have spinal cord injury, and therefore I have an indwelling Foley catheter which drains the bladder. I train my own attendants or anyone to assist me with that, and already I am getting questions saying, "Well, am I still allowed to do this?" or "Is it illegal for me?" This is what is happening at the grass-roots level. As Ian said, it was never the intention of the bill, of course, to produce this sort of meaning, but this is how people are interpreting it. Over the last 12 years, there has never been one problem with one person who has assisted me in this procedure. But they are very worried, so we want to see this thing taken care of in a way that I can point to it and say, "Look, it's okay, you can carry on what you're doing," and I can live happily ever after.
Mrs McLeod: Your amendment seems like an eminently sensible and clearly written way of dealing with the problem. Can I ask you directly whether there have been any objections raised about the specific wording of the amendment you propose?
Mr Parker: No, there have not. It was put before those organizations on our behalf by the Ontario Medical Association, and there have not been any changes in the wording whatsoever.
Mr Hope: How do you rest assured that quality assurance is there, in some of the day-to-day routines? How do you know whether you are getting the proper service?
Miss Self: It is in my hands. The quality is in my hands. I direct the person assisting me step by step, and that is how I want the quality to be, resting with me. It is my responsibility. That is the whole foundation of attendant services. That is how it was formulated in the beginning. That was the arrangement with the ministry. That is what it has been built on. For people receiving the service, one of the main priorities of eligibility is that you do direct. As soon as you pass responsibility over to the person providing assistance, it changes the whole scene, and it does not work that way anyway. I want to be the one in control.
Mr Hope: What I was getting at specifically is dealing with the insertion of the catheter.
Miss Self: Maybe I will describe that, because that is a clear example. In a hospital, for example, it is taught as a very sterile procedure. It is certainly done by a registered nurse or someone qualified to do it. They are responsible for the outcome, and the patient is a passive recipient of what is happening. In my situation, I do not use the same procedure at all; it is just a clean technique. Basically, I pay for the catheters, which are $15 apiece. You do not throw them out each time. I change it every day. In fact, I reuse them, which you would never do in hospital. My technique is totally different. I have never had a bladder infection in 12 years. I have never had antibiotics or been hospitalized.
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So when you are looking at quality, it is not relating to a sterile, taught procedure; you are looking at other things. You are looking at basic things like competence. What we are always having to prove at every debate and every discussion is that, yes, I could show anyone step by step. It is my competence I am always having to justify and prove.
Mr Parker: The important distinction, I think, is that in a hospital, most of the people there are unstable care. It can go wrong, because they are not stable, whereas we have been doing it for so many years, learned how to do it in hospital, and it is just so routine it is second-nature to us that we know what we are doing. In fact, if we were to go into a hospital, we would be training the people there to do it our way.
The Chair: Thank you very much for an excellent and thoughtful presentation. I believe it is very helpful for members of the committee to hear directly from consumers, and we have heard a number of presentations similar to yours. With each one, we have assured the presenters that it is the goal of all the members of this committee to ensure both the independence, as well as the personal control, that you have identified, to be sure that this legislation does not impede that. We appreciate the work that you have done in developing an amendment which will be considered by the committee.
KAREN KAHANSKY
STEFAN FRIDRIKSSON
The Chair: I would like to call Karen Kahansky and Stefan Fridriksson. The committee has received the documentation that you presented to the clerk, and it becomes part of the public record.
Ms Kahansky: Since audiologists are the ones requesting hearing aid prescription as a legislative act, it is up to us to demonstrate that the public is better served with this legislation than without it. The two main issues I would like to address today are overamplification and middle ear pathologies requiring medical intervention.
With regard to middle ear pathologies, there are certain danger signs that are readily apparent to the trained eye through an otoscope. If, for example, a middle ear infection remains undetected, complications that can arise include perforation of the ear drum, cholesteatoma, facial paralysis, brain abscess, meningitis or permanent sensory neural hearing loss. In his letter to this committee, Dr Mendlesohn states that only university-trained professionals be allowed to prescribe hearing aids, as we have the necessary training in the anatomy of the ear.
Deterioration of hearing due to overamplification has been so well documented in the literature that it is now considered indisputable. In addition, ear specialists have clinically reported aggravated tinnitus due to overamplification.
Thus far, I have limited this discussion to the possible physical harm that can result from incomplete assessments and inappropriate hearing aid prescriptions. In closing, I would like to leave you with the question, what about the social devastation of an incorrectly fit hearing aid?
Mr Fridriksson: In 1987, audiologists accepted the grandfathering of all hearing aid dealers who were prescribing hearing aids at that time. Because we accepted the grandfathering, we now find ourselves in the position where we must prove that future hearing aid dealers do not deserve the same right.
We ask ourselves, why would this committee allow hearing aid dealers to prescribe hearing aids? Is it because they are well-trained? In defence of their skills, they told you that some of their members had graduated from a one-year training program at Sheridan College. This implies that a college training program would be adequate training for the prescription of a medical device. This notion contradicts the consensus report of the 1990 Vanderbilt international symposium on hearing aid prescription. In reference to the necessary qualifications, the opening words of the conference's consensus statement are, "The first decision that must be addressed when prescribing a hearing aid is whether a person is a candidate for a hearing aid." This statement implies audiologic diagnosis.
The prescription of a medical device requires that someone make a diagnosis. It has been clearly stated by physicians that they rely on audiologists to make the diagnosis of a hearing loss. Every day, they send me patients for these diagnoses. None of these patients wear labels proclaiming their ailment. They might have normal hearing, chronic middle ear disease, a dead ear, a middle ear malignancy or even a brain stem tumour.
How do hearing aid dealers propose to separate the routine hearing losses from the ones that require further evaluation? They are not trained in differential diagnosis, site-of-lesion testing, case history analysis, medico-legal testing or use of clinical equipment. This training is not to be had in the college training curricula. In the arsenal of the hearing aid dealer, they have but one skill and one solution for a hearing loss: Fit a hearing aid on it. And they do.
Is there potential harm in allowing hearing aid dealers to prescribe a hearing aid? I have letters from ear specialists documenting cases of hearing aid dealers fitting all of the above types of hearing loss with hearing aids. I have letters from seven eminent authors and researchers documenting cases of harm caused by hearing aid misprescription and overamplification.
Is it because hearing aid dealers have demonstrated skills that impress other professionals? It is their lack of skill that prompted the WCB, Metro social services and virtually every insurance company in Canada to require an audiologist's prescription prior to a hearing aid fitting. In his letter, Dr Wilfred Goodman, an ear specialist and the WCB's chief adjudicator, asks this committee if it is appropriate to allow opticians to prescribe eyeglasses. Obviously not. Then why, he wonders, would you consider it appropriate to allow a hearing aid dealer to prescribe a hearing aid?
Is it because experts from the field have told you that hearing aid dealers are qualified to prescribe hearing aids? I have letters from the chief otologists of seven major Metropolitan Toronto hospitals, and promises of letters from six more, urging you, in the interests of the protection of the public, to give the exclusive, licensed act of hearing aid prescription to audiologists. I have letters from internationally recognized authors and researchers telling you that audiologists are the only professionals with the skill and knowledge necessary to prescribe a hearing aid. Despite all of this, audiologists are still willing to honour the 1987 grandfathering.
As MPPs you can determine the standards of health care in a field you know very little about. Hearing loss is a disease that deserves to be taken seriously. Audiologists are asking you to do just that.
The Chair: Thank you very much for your presentation. I know you realize that if there is any additional information you think would be helpful, you can submit that to the committee in writing, although we did receive your very substantial brief.
Mr Fridriksson: We have left five minutes for questions.
The Chair: Yes. There are none.
Mr Fridriksson: No questions? Can I address some questions to you?
The Chair: If you wish. You can always submit them in writing.
Mr Fridriksson: If I could just say them?
The Chair: Sure.
Mr Fridriksson: I spoke to all the different heads of the otology departments in the Metropolitan Toronto hospitals and some in the Ottawa hospitals, and they were concerned that we are about to allow this to happen. As you will see in their letters, there are so many cases. It is not just an isolated case of a brain tumour being fitted or a middle ear malignancy being fitted or a middle ear disease that has been fitted with an occluded ear mould that causes the middle ear malignancy to continue or to become a brain abscess or something like that. These are not isolated cases.
The Chair: I would not interpret the fact that there are no questions from committee members as any bias one way or the other.
Mr Fridriksson: No, I understand.
The Chair: We have had a number of presentations.
Mr Fridriksson: Addressing the same issue?
The Chair: Yes. I can assure you the committee is well aware of this issue. They have heard it. They have received the documentation. It is recorded in Hansard.
Mr Fridriksson: Excellent.
The Chair: So do not feel because there are no questions that in any way you have not been heard.
Mrs McLeod will make you feel better. She has a question.
Mrs McLeod: I am just wondering, because of the concern you have just reiterated in wanting to add those last comments, whether you have had some clear indication that the proposals that are currently in legislative form would be changed.
Mr Fridriksson: I am worried that somehow future hearing aid dealers will be allowed to do to my patients what I have seen. Yesterday I saw a man, 82 years old, have a hearing aid fit on a dead ear.
Mrs McLeod: But you have not had any indication that this would in fact be allowed?
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Mr Fridriksson: I am concerned. The presentations I heard last time that there is no possible harm from misprescribing a hearing aid -- I wanted to clarify that there are so many cases. I am worried -- obviously not for my sake; I do not wear a hearing aid -- but for my patients' sake I am worried. I am worried that somebody is going to get killed. I mean it. I have a letter from one of the doctors who came that close with a patient in Orangeville, and I am worried that another patient could go through the same thing she went through: two months of really bad pain from a middle ear being fit.
The woman had chronic middle ear infection and she was fit on that ear despite the fact that she told the hearing aid dealer she had chronic ear infections. She was assured that it would not hurt. She was fit on that ear and two weeks later she had the smelliest ear. You would have to stand that far away with your otoscope to look in there. I am worried that this kind of thing will continue.
Mrs McLeod: But if the legislation goes through as proposed, your concerns are addressed.
Mr Fridriksson: I want it to go through as it is proposed, and I want you also to notice the letters. I have 62 of them personally written to me saying that they support diagnosis of hearing loss and its communication. Last time I had not read as clearly as I should have, and I said that some of them did not specifically state that they wanted us to communicate our diagnosis. But I have clarification letters from every single doctor who wrote me a letter, a total of 62 doctors. If every audiologist in the province went around and collected them -- 259 times, and let's say we each got 15 or something like that -- it is obvious the medical community wants us to tell the patient they have a hearing loss. We are the ones who diagnose it; we should be the ones to say, "You have a hearing loss" and explain it.
The Chair: I can assure you that you have been very clear on the position you have put forward. We appreciate the documentation you have provided us with.
Mr Fridriksson: Thanks for your time. There is some more documentation.
The Chair: Just submit it to the clerk, and if over the course of our deliberations there is additional information, we are happy to receive that at any time.
The committee adjourned at 1542.