Thursday 29 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

Algoma Child and Youth Services

Ontario Pharmacists' Association

Algoma Home Care Program

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

Ontario Nurses' Association, Local 46

Family Services Centre

Tom Hendrie

Joyce Isbitsky

Ontario Public Service Employees Union

Nutritional Consultants Organization of Canada

Ontario Secondary School Teachers' Federation, Sudbury

Michael Hamilton

Sudbury Nurses for Life

Rick Geroux

Pat Jolin

J. Denny Wilkinson

Algoma Physical Rehabilitation Clinic


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)


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

Sola, John (Mississauga East L) for Mrs McLeod

Wessenger, Paul (Simcoe Centre NDP) for Mr Malkowski

Clerk: Mellor, Lynn

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

The committee met at 0918 in the Water Tower Inn, Sault Ste Marie.


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

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


The Chair: I call first Algoma Child and Youth Services. You have 20 minutes for your presentation and for any questions members might have.

Dr Cheston: Thank you for the opportunity to pronounce our concerns with the proposed Regulated Health Professions Act and the Psychology Act. We are from Algoma Child and Youth Services. I am Dr Patricia Cheston. These are my colleagues Dr Alan Gelmych and Dr Jay McGrory. We also have presenting with us Deborah Brooks, who is a member of the Ontario Board of Examiners in Psychology. She is a public representative.

We would like to express our agreement with the direction of the proposed legislation. We are comforted by the fact that many professionals who are currently unregulated will now be regulated. Due to fewer resources, it is our opinion that rural areas such as ours in northern Ontario are more vulnerable to unregulated individuals practising and being viewed as psychologists. We were going to address the issue of psychologists practising outside of the Ministry of Health. However, we have received information that this issue has been largely clarified for psychology.

However, we do have concerns about protection of the terms "psychology" and "psychological." We view this as a consumer protection issue, and we have invited Deborah Brooks to read a letter she has written which we feel addresses this issue.

Ms Brooks: The letter referred to was submitted to Tony Martin. My comments today are on the same topic, but they deviate slightly, as I wanted to be a little briefer. I am here today to support the petitions presented to you by the individual psychologists with respect to changes required in the proposed Regulated Health Professions Act.

I am a public member of the Ontario Board of Examiners in Psychology and have so far served in that capacity for two and a half years. I was active in special education issues in Sault Ste Marie for many years. I have served as a director of the Sault chapter of the Ontario Association for Children with Learning Disabilities and as a member of the public school board's special education advisory committee. I am also a parent of a learning disabled child who has been on the receiving end of psychological services for most of his formative years.

It must seem incredible that a piece of legislation could go through so many years of development, be subject to so much debate and discussion, pass the microscopic inspections of dozens of legislative experts yet still be so drastically flawed. Yet with respect to the practice of psychology in Ontario, the regulated health professions legislation is flawed. Instead of strengthening public protection from unqualified, incompetent and unfit providers, it would remove from the scope of regulation and therefore from statutory accountability almost half of the psychologists who are presently registered in Ontario. This would include all those whose practices are not health care, such as educational psychologists and industrial psychologists.

Instead of improving the mechanisms which allow the public to make informed decisions when exercising freedom of choice of care providers, the proposed act would strip the terms "psychological" and "psychology" of their common usage as descriptors of a regulated practice. The public will have no consistent means of distinguishing between regulated and unregulated practitioners for either health care services or non-health-care services.

I ask you to review carefully the submissions you will receive today and those previously submitted to you by the Ontario Board of Examiners in Psychology and the Ontario Psychological Association. They present the problems with the proposed legislation much more completely and offer very sensible solutions. These are not trifling complaints, nor are they in any way self-serving to the profession. The changes which you are being asked to make are vital to the welfare of thousands of Ontario citizens who are in need of psychological care.

Dr McGrory: To summarize for many of the people who have just joined us, we are discussing some of the concerns that we as psychology professionals in Sault Ste Marie are particularly concerned about in the proposed legislation. Two key issues are, first, the issue of the application of the legislation to people outside of health; our understanding is that this may not be an issue any longer. The second issue that is clearly outstanding is one that pertains to the regulation of the terms "psychological" and "psychology," which are presently regulated terms and are not used outside of the scope of a psychologist's practice, but according to the new legislation will not be regulated.

The Ontario Psychological Association commissioned a poll and found that the public does not discriminate between the terms "psychologist," "psychological" and "psychology." If one or two of the terms are not regulated in the proposed legislation, our concern is that the consumers and the public will not be able to discriminate and will not be able to determine which are regulated professionals and which are not. Examples, which I am sure you are aware of, would include terms such as "psychology consultant" and "psychological practitioner." Even services or centres such a psychology centre would not, in our interpretation, fall under the jurisdiction of the proposed legislation.

That is very disconcerting for us, particularly for the children and families we work with. We appreciate the opportunity to present our concern and are willing to take any questions.

Mr Martin: As we have gone through this month and heard of some of the concerns you have raised this morning, and certainly we have heard them a number of times from various organizations, a dilemma is posed for me and I think for some of the other members, and I guess it cuts to the heart of this legislation: How do we protect the public from people who are not qualified and yet how do we provide services, particularly to northern areas and remote communities, in perhaps more creative ways? The issue you bring up in terms of tightening up the language and some of the classifications may make it more difficult for northern communities to get the people they need to do the job, because we cannot all either access or afford the psychologist. Do you have any comment on that? That is a concern for me and I am sure it must be for you as you service areas around the Sault.

Dr McGrory: Clearly, we here in the north recognize that trained professionals are a rare commodity. However, legislation that would allow untrained professionals, particularly individuals, to write psychological reports, for example, to provide psychological assessment without any regulating body would not, in my opinion, be helpful to the public in general and/or solve the issue which is a current issue of being able to provide more creative or more diverse mental health services.

Mr J. Wilson: You raise a number of points I have heard before, but following on Tony's lead, I was wondering how many non-doctoral practitioners you have in the area versus PhDs, actual psychologists, registered.

Dr Cheston: You mean within psychology or within other professions?

Mr J. Wilson: We had testimony earlier that there are a number of people with MAs, for instance, practising the profession legitimately. My worry is with title protection. Although you have the terms "psychological" and "psychology" protected now, they are kind of out there, outside of this legislation. You are in negotiation with the College of Psychologists of Ontario to try to get the MAs recognized. If we go ahead and extend the protection to those terms again, we may pre-empt that process.

Dr Cheston: Currently if the MAs do psychological assessments and so forth, the reports are co-signed by a registered PhD psychologist. There is a certain quality assurance to the reports in that way. I do not see it as an issue of preventing other people from practising. I see it as an issue of giving the public more clarity in terms of whom they are seeking services from.

Mr J. Wilson: But what if the MAs who are currently trying to become members of the college are not successful over the next 18 months in negotiations. Will it effectively bar them from practising psychology? They will not be able to say they are providing psychological services, for instance, because they will not be members of the college and will not be entitled to the title protection.

Ms Brooks: I would like to comment on that. The public members of the college have identified and have raised concerns with the college over the MA issue and are very much in support of bringing an MA-level type of provision under the scope of the college; I understand there has been a draft agreement or whatever drawn up between the MA group and OPA and OBEP. But I want you to know that by removing protection from the terms "psychology" and "psychological," you water down regulation. What is needed is for the regulation to apply to a broader range of psychological services. That would be achieved by bringing the MA-level practitioners under the scope of regulation in some way. The lay persons see that as really an important issue, that the MA-level practitioners be regulated.


I think the OBEP submission to you has commented on a number of complaints that come to OBEP about unregulated practitioners. The people involved are quite surprised when they find out that the psychologist or the counsellor they have been seeing is not a regulated professional. It is important that those issues be addressed.

That, when you look at it very carefully, is separate from the title issue. By not giving protection to the titles "psychology" and "psychological," it will not solve that problem. It will just make it worse. It will be more confusing.

Mr Beer: Without this protection, if someone is being hired by a school board, surely the school board knows whether that person is a psychologist and registered. Playing devil's advocate a bit, is there not a responsibility as well on the consumer, on the body that is hiring the person, to make sure that individual is indeed what he or she says he or she is, and does not subsection 15(2) also address that issue?

Dr Isbitsky: Can I respond to that?

The Chair: You will have to come to the table. Are you part of the delegation?

Dr Cheston: This is Dr Joyce Isbitsky. She is doing a presentation at 11:30.

Mr Beer: I will repeat the question later. I think we need to be clear on some of these issues, and I wonder where the balance is and why 15(2) would not provide that protection.

Ms Brooks: Having sat on tribunals where psychologists were in employment settings, there was often a conflict between the ethics and standards of conduct and practice required of a professional psychologist under the act and what his employer wishes him to do. That conflict does exist, and I have seen evidence of it in tribunals and in disciplinary proceedings.

It is not good to leave it up to employers, even if they are boards of education or hospitals or whatever. Their interests are often not compatible with what a psychologist would consider to be ethical; for example, disclosure of information and confidentiality, to name one issue. They are in conflict.

Mr Owens: On the issue of supervision and quality assurance, it appears that the current practice is that the MA performs the assessment and then the PhD simply signs off on the assessment.

Dr Gelmych: Not necessarily.

Dr Cheston: Usually a PhD is supervising; that means he or she will go over the raw data with the MA person. The PhD person is responsible for what goes in that report and the interpretation of the data and the recommendation. Although the MA person may actually write the report, it is not a matter of just reading it and signing it off.

Mr Owens: Would that practice change and how would it change if you folks were regulated or were part of the college as the PhDs are and will be? Will that practice change at all?

Dr McGrory: If our interpretation is correct that under the legislation the terms "psychological" and "psychology" are not regulated, presumably it would mean that anybody could write a psychological report, which is what the title of our reports are now, without supervision of a psychologist.

The bottom-line issue is that certainly many MAs are quite competent and are able to do that. I do not think we are concerned with the MAs. What we are concerned with is untrained people presenting themselves as professionals, writing reports that may be construed as professional reports, but who are not regulated and with no regulating body for the consumer to respond to.

Mr Wessenger: I have a comment with respect to the whole question of providing health care. It should be understood that it is not the site where the service is provided; it is really providing health care whether that is in an educational institution or in a health facility. It really does not make any difference.

The Chair: If there is any additional information over the course of our hearings or deliberations that you think would be helpful, please feel free to submit to us in writing by our clerk.


The Chair: I call the Ontario Pharmacists' Association. You have 20 minutes for your presentation.

Mr Krall: My name is John Krall. I am the immediate past president of the Ontario Pharmacists' Association. I am presently chairman of our ad hoc committee, which has reviewed this legislation. With me today is Gary Sands, our manager of government and public affairs.

The Ontario Pharmacists' Association is a voluntary professional organization representing approximately 4,000 pharmacists in Ontario. Under enabling legislation passed in 1986, OPA negotiates with the Ministry of Health on behalf of all pharmacists for the professional fee paid to pharmacists under the Ontario drug benefit program.

On behalf of our elected council, I want to thank the committee members for this opportunity to appear before you today and outline OPA's position on the Regulated Health Professions Act.

Notwithstanding some concerns, the Ontario Pharmacists' Association wishes to indicate its support for the proposed legislation presently known as Bill 43 and Bill 61, the Pharmacy Act.

The primary purpose of this legislation and the basis of OPA's response to it is the protection and safety of the public. Our association also accepts that the legislation was intended to strike a balance between preserving the concept of self-regulated health professions, while at the same time ensuring public accountability. It is within this context that we outline our concerns with certain sections of these bills.

Our first concern is the controlled act exemption. It is recalled from a briefing by Ministry of Health staff last year that its main objectives were to level the playing field and to make the public interest paramount. It was these principles that resulted in the designation of controlled acts along with the prohibitions set out in subsection 26(1) of Bill 43.

However, clause 39(1)(b) of the same bill allows the minister to exempt a person or activity from subsection 26(1). Our association does not comprehend the rationale for this exemption provision, nor does it accept that government interest and public interest are always convergent. The government must be subjected to the same rule of the level playing field as the professions.

The issue has been raised with Ministry of Health staff, and no explanation or rationale for the exemption provision has been given to the Ontario Pharmacists' Association.

Therefore, we would agree with the Minister of Health when she said, "The 13 controlled acts provide ample protection for consumers," and would further submit that allowing the minister to arbitrarily exempt a person or activity from the regulations that health professions will use to govern themselves does not conform to the spirit of this legislation.


Under the subject of titles, the proposed legislation will ostensibly prevent any pharmacist who holds the PharmD degree or the PhD degree in pharmacy from using the title "doctor" as a vocational designation. These degrees are highly regarded by our profession, and the obtaining of such should be encouraged and appropriately recognized.

The Ontario Pharmacists' Association joins the Ontario College of Pharmacists and the Ontario branch of the Canadian Society of Hospital Pharmacists in asking the committee to amend section 30 of Bill 43 to permit duly qualified pharmacists to use the title "doctor."

Hospital exemption: Under the Health Disciplines Act, the provision of drugs in a hospital, health or custodial institutions has been exempted from the regulations laid out in the Pharmacy Act under the Health Disciplines Act. This exemption has been maintained under the proposed legislation before this committee.

The Ontario Pharmacists' Association believes that the practice of pharmacy, as defined in section 3 of Bill 61, in a hospital, health, or custodial institution must be directed by a pharmacist who is accountable to the Ontario College of Pharmacists for his or her professional activities. In the public interest, the current blanket exemption cannot be justified, and we urge it to be amended accordingly.

The midwifery amendment: The draft amendments tabled with the committee on August 6 included an amendment to section 4 of Bill 66. One new clause will allow midwives the right to prescribe drugs. While the minister referred in her statement to an unknown "limited list of medications," our association has some reservations about this proposal.

As the report of the Pharmaceutical Inquiry of Ontario, chaired by Dr Lowy, pointed out last July, the issue of proper prescribing practices is already something that is challenging the medical profession.

Pharmacists have no objections in principle to the concept of midwives prescribing drugs. Indeed, this may represent an area where traditional medicine can utilize conventional medicine for the betterment of women.

However, we understand there is at present no specific educational program in Ontario for midwives that provides training and education in pharmacology and therapeutics. We believe an adequate knowledge of pharmacology and therapeutics is essential and that the corresponding educational requirements should be put in place for midwives.

In addition, would the right to prescribe drugs also allow for their purchase? We understand from ministry staff that this would, in fact, logically allow midwives to purchase or acquire certain drugs. This too requires clarification.

The current safeguards over the provision of drugs to the public has been accomplished through professional regulation and the rules of pharmacy ownership. A weakening of these strict controls poses serious ramifications.

We would suggest the amendment allowing the prescribing of drugs by midwives be reviewed with these points in mind. Since the minister has indicated that the regulated health professions will be continuously reviewed, we would be more than happy to participate in a further review of this amendment.

Membership of college council: The Ontario Pharmacists' Association supports self-regulation with an appropriate balance of public representation of councils. The Health Professions Legislation Review headed by Alan Schwartz stated, "Self-regulation cannot function successfully unless the individuals regulated consider it to be a fair and appropriate balance," and suggested that one third of the council membership be composed of public representation.

In March 1991, the Premier's Council on Health Strategy also made a recommendation related to public participation on governance structures, which include "governmental and quasi-governmental authorities and committees, and boards of publicly funded agencies." The council recommended in objective 2.2: "By 2000, ensure that the representation of consumers of health and social services be at least one third of the membership on governance structures."

Public membership of just under 50% poses a serious threat to the concept of self-regulation. Again, as the Schwartz review pointed out, the complex and specialized nature of professional work demands that professionals play a significant role in their own regulation.

While we appreciate that the government's intention is to increase public membership above the one-third level, the Ontario Pharmacists' Association feels that the rationale for the recommendation of the Schwartz review and the Premier's Council should be carefully considered. We would suggest to the committee members that public membership of just under half, in a system of self-regulation, is not an appropriate balance.

I would like once again to thank you for listening to our concerns, and we certainly would welcome any questions from the committee members.

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

Mr Wessenger: I would like to have ministry staff clarify a couple of the points raised in your brief.

Mr Burrows: I would like to clarify a couple of things. First, with respect to the controlled act and exemption, there must be some misunderstanding in terms of communication with the ministry, because as recently as a week ago Mr Sands and I had a discussion on this subject and I did provide him with rationale, but I am pleased to reiterate that.

I think it is important to read the whole section. Section 39 starts with, "Subject to the approval of the Lieutenant Governor in Council, the minister may make regulations," and there is more than one thing that is covered in this: "(a) prescribing forms of energy," which the committee has heard about previously; "(b) exempting a person or activity from subsection 26(1)," which is the controlled acts; "(c) attaching conditions to an exemption in a regulation made under clause (b);" and "(d) allowing the use of the title `doctor.'" So there is a series of things.

But I would like to point out, first, that the minister alone would not make such a regulation, that these regulations would have to go through due process. In terms of due process, under this act it is envisioned that regulations of all types, regardless of their source, would be discussed and vetted by the advisory council, and the process for the advisory council is such that it would be an open and public one.

Also, the test of the public interest would have to apply. I have discussed this with legal counsel, and an arbitrary exemption would be subject possibly to review, and it would have to be defended if it were challenged on the basis of the need for the public interest.

It is also envisioned that situations could develop such as a pressing need, for example, a natural disaster in an area of the province where there were not sufficient regulated professions to cope -- a good example would be areas of northern Ontario -- and the government must have the ability to move very quickly to approve things if such a situation were to develop.

Specifically, the need for exemption has already been brought before the committee too in such things as a simple procedure like ear-piercing, which, if there were not an exemption, would be illegal -- acupuncture and so forth. So it is designed as a mechanism for flexibility.

I would also like to point out that this particular exemption has not apparently been a problematic one for most of the other health professions we have dealt with, with respect to the development of this legislation.

With respect to the midwifery amendment, I would simply like to say that what is envisioned is a situation that is not unlike that which presently prevails for optometrists. Optometrists are able to use a short list of drugs which is provided for by regulation. We would expect the same sort of thing here.

Certainly the government would not disregard the opinion of Dr Lowy with respect to the need to protect the public. It might be advisable, if the Ontario Pharmacists' Association has specific suggestions in this regard, to make its views known to the interim regulatory council on midwifery, which is charged with, among other things, working on the educational program. Clearly, if midwives are going to be authorized to use drugs, they would need some appropriate training in that regard.

Mr J. Wilson: I would like to ask about your comments on the controlled acts exemption. Is it just the inconsistency you see there that you are not pleased with, or can you give us something more concrete about how this could be detrimental?

Mr Sands: Going back to Alan, the first thing to clarify is that yes, Alan and I did discuss it last week. Unfortunately, the brief had already gone to the council for approval. They still felt it was contrary to the spirit of the act, and we had corresponded with the branch a couple of times and had no explanation or rationale received. But the opinion of the council is that it still feels that mechanism is contrary to the spirit of such a regulation.


Mr Beer: I would like to ask you a question about your comments around the membership of the college council. The points you raised there are somewhat similar to some that were raised yesterday by the College of Physicians and Surgeons. In their proposal to us they suggested a 60-40 split. One of the questions that arose as well was about academic deans being involved in the council; I guess there is just one academic dean so it may not be the same issue with you. Could you elaborate on where we might find the perfect balance between one third and just under one half which you believe would provide the balance for self-regulation you are looking for?

Mr Krall: I am not sure I have that solution with me today. I am sure this committee will solve that. We merely wanted to point out our support for some point in between, and we think that is a reasonable compromise that would both protect the public yet leave our profession as a self-regulated profession. I still believe that if it is a true profession and we are self-regulated, things will be done correctly. If they are not, the government has certainly got regulations to make sure they will be taken care of in the future.

Mr Sands: Just to add to that, the colleges are different. Just to point out to the members, if the academic is the mechanism by which the government is looking at possibly addressing the membership issue, for some like medicine I believe it would be around five, but for us it would be more. It is still, as far as the college is concerned, not workable.

Mr Owens: I would like to thank Mr Sands for coming all the way from Scarborough Centre to make his presentation to us this morning.

I have a question with respect to your comments on the hospital exemption. How would you see the exemptions working, understanding that there may be a need for some exemptions out there? How would your association approach making those exemptions?

Mr Krall: At present, all hospital pharmacists are exempted. One of the discussions that took place was: "Include everyone. We realize there are going to be some areas of the province, some locales that have a difficult time obtaining the services of a pharmacist, but rather than giving the entire province a blanket, let's exempt those areas that perhaps have a problem, but let's not just leave the problem there. Why don't we work together to try to solve those problems?"

Mr Owens: Would you have any recommendations you could make to this committee or the interim advisory council?

Mr Krall: At the moment my recommendation would be that we sit down and try to work out a solution. I did not bring a brief with me on how to solve that problem, but I can assure you that, with the public good involved, the Ontario Pharmacists' Association would look to see what it could do to help.

Mr Johnson: Following Mr Owens's questioning, just how widespread is this concern you have about the hospital exemption? Are most hospitals staffed by pharmacists, or could you give me some numbers? I know that often in smaller centres they are like a dispensary more than an actual pharmacy, but certainly in larger centres I would imagine they would be equivalent to a full-blown pharmacy. I was wondering if you could give me some numbers.

Mr Krall: To be frank, I do not have those numbers. They are certainly obtainable, probably through the college, to determine how many hospitals do have licensed pharmacists on board.

Mr Johnson: I asked because I was wondering what you are basing your concern on. I know that if there were an exemption under the Health Disciplines Act, then this will continue under the new regulations.

Mr Krall: We expressed that concern in the past; this is not a new concern. Speaking frankly to the committee, the concern is really for the public. Pharmacists are already there, already serving the public in all these institutions. The pharmacists who are working there are asking also to fall under the regulations. I see it as a win-win situation to have them included. It protects the public. It makes the profession more responsible. I see it as a total win situation.

Mr Sands: Just to add to it, Mr Johnson, you might want to ask Mr Schwartz about it when he is before the committee. We did discuss it with Mr Schwartz. For some reason it was not addressed in the report, I believe. I understand that the rationale for not dealing with it is financial concern on the part of some hospitals. We believe the financial concerns are not that significant in terms of the overall considerations, and when you weigh those concerns against the public interest of having all pharmacists covered under the act, we come to the side of the public.

Ms Haeck: I want to address the issue of the title "doctor." Definitely my own concern is that there is a certain amount of confusion in a hospital setting. When you are talking about using "doctor," do you mean at the pharmacy or in a hospital setting?

Mr Krall: The title we are looking for is the PharmD In Ontario at present almost all of these people are working in hospitals, and the vast majority of them are working in hospitals in Toronto. It is possible that some of these people could possibly work in the community; it is a possibility. Their degree would say "doctor of pharmacy."

The Chair: I have an appeal from Mr Hope for a short supplementary.

Mr Hope: To follow up on Mr Beer's comments, you said the just under 50% poses a serious threat. By my recollection from dealing with this, as long as you have 51% you still hold the dominant vote on these councils. That is why I do not understand where you say it poses a threat. As long as you have the majority vote on the decision process, where is the threat?

Mr Krall: I guess the word "threat" is a pretty strong one. The significant word is probably "self-regulated." With some of the material and experience we have had to deal with, I think the word "threat" is probably a strong one. But in the public interest, balanced with the self-regulated principle, I think somewhat less than that would probably be beneficial to both parties.

The Chair: Thank you for your presentation before the committee this morning. We appreciate your taking the opportunity to appear before us. We know you are aware that if there is additional information you would like to share with us, you can do so at any time in writing, addressed to our clerk.



The Chair: I call next the Algoma Home Care Program. Welcome. We are very happy to see you this morning. You have 20 minutes for your presentation.

Ms Hamilton: My name is Anna Hamilton. I am the administrator of the Algoma Home Care Program. I thank the committee for this opportunity to make this presentation, and my brief will be brief.

I am concerned with Bill 43, subparagraphs 26(2)6iv and vi, and also paragraph 26(2)5. They refer to catheterization; the next deals with bowel routines, going past the anal verge; and the third is injections.

I would like to outline three specific situations, because I am not sure how else to describe the problems that arise from this. Unfortunately, the legislation with those controlled acts lumps people with stable medical conditions in with people with unstable medical conditions who may require those treatments. That can create real problems in the community.

The three situations I would like to describe are a child with spina bifida in grade 1, a quadriplegic living alone, and an elderly person who is insulin-dependent who is also living alone.

The child with spina bifida in grade 1: Children with spina bifida usually require catheterization in order to empty their bladders. Catheterization requires passing an instrument "beyond the opening of the urethra." As children mature, they usually develop the muscular and hand-eye co-ordination to do this independently. However, until their skill is developed, someone else has to do this for them. When they enter school for a full day, this procedure must be done at least twice during the school day. Even for the kids going into kindergarten a half-day, it usually has to be done at least once from the time they leave home until the time they get back, depending on the circumstance.

The child in question is being taken by bus to school, so is unable to return home during the school day. Both parents work outside the home and are unavailable to go to the school to provide care for the child. The child does not usually have the necessary skills at this age to do the treatment independently. Under the legislation as it is presently being discussed, the only solution to the problem would be to have a registered nurse available when the child needed the help.

This immediately brings up several problems. The major one is that it results in a focus on illness because a nurse is required. This focus interferes with both the child and those in the child's immediate environment learning to accept the "child with a chronic condition" rather than "a chronically ill child." While the words in the two expressions sound very similar, in fact, from a philosophical and an attitudinal approach, they are almost diametrically opposed. In the first instance, the child is seen as a child, as an individual, and is not being defined by the child's medical problem.

A second problem is that having someone come in from outside the child's school environment is intrusive and disruptive. It is not the best way of meeting the needs. Even with the best effort to time a visit, there is little guarantee the visits will consistently happen when the child needs the visit and when the school schedule can best accommodate the visit. The care must be given when the nurse arrives, even if it means the child has to be withdrawn from a classroom while a class is in session. When this occurs, attention is immediately drawn to the child and emphasizes to the child and to the others that the child is different. The main advantage of using an individual who is already present in the child's school environment is that the care is available as soon as the child needs the care and the care simply becomes a part of the child's everyday environment; it is a task which must be done. It de-emphasizes the whole thing and basically does not permit the child to start manipulating around the whole fact that he has this problem.

A third problem is recruitment of nurses to provide these services when and where the child requires them. Algoma is no different from other areas in Ontario when it comes to having schools in sparsely populated areas. For example, the Montreal River School is approximately one hour north of Sault Ste Marie. If a child requiring catheterization were to enrol in that school this September, there is no source of nursing service for that child at this time. Even if a nurse lives in the area, there is no onus on that nurse to provide service for that child. They may not choose to do that type of work. Given no available professionals, must the parents move to an area where the service is available? Or should the child not be allowed to attend the closest neighbourhood school and be forced to take a bus to the school in an area where the service is available? Neither of these solutions are acceptable if there is a true commitment on the part of the system to integrate these children into their own neighbourhoods.

All these comments I have made pertain to children with stable medical conditions. For these children, it is my strong belief that if a parent can be taught to provide such treatment, then an attendant or aide can also be taught to care safely and effectively for the child. However, the safeguards that must be built in are adequate training for the care giver, adequate and ongoing supervision by a health care professional, and adequate updating -- that is, in service -- if the child's needs change.

The other situation is a quadriplegic living alone. This is happening more and more. We have got to the stage where we are actually freeing these people to go out and live their lives and make their own decisions and take care of themselves.

If, for example, the individual was on a bowel routine that included the use of enemas or suppositories, this legislation would prevent that person from hiring someone other than a nurse to carry out this particular function. If the individual were male, he may prefer a male attendant for all such personal care and be unable to find someone in his immediate area to meet his needs, because male nurses are not all over the place out there, while there is a larger pool of individuals to choose from if the criterion of "nurse" is taken off and you are simply looking for a male.

This legislation will again create more barriers for disabled persons in the area of personal care and will take some of their control back from them. This is a step backwards in time.

If what control the disabled have gained is not to be forfeit, then the health care system must face staggering increases in costs to meet their needs. There, I simply mean that if we are saying it must be a nurse, then the health care system had better come up with a nurse to provide the care when the person needs it.

The elderly person who is insulin-dependent: Many of these people do very well doing their own injections. As time progresses, they may become less able to do it. For varying reasons, the individual could no longer do her own injections. Her neighbour in the seniors' apartment building was willing to learn how to do the injections to help her friend out. This legislation would preclude such help from the informal care-giving network unless the person needing care lived in the same household with the person giving care.

What seems to be missing from the act is a definition of what constitutes a person's household. From a community health care perspective, this creates real problems. Does the same roof overhead define it? Does some relationship established by law or by blood define it? Can the daughter-in-law of an individual who lives in a different part of town come in daily and give the insulin? If the requirements of the legislation result in a nurse being the only answer, a problem arises when the individual lives in a relatively remote community with no availability of daily nursing visits. Again, I am talking about simply finding the bodies to do the work that seems to be needed. Should the individual be forced to move to where service which meets the demands of the legislation is available to him or her?

Those are the three situations, and I would suggest that in none of them would having legislation that requires it to be a nurse giving the care be in the best interest of the individual. Free choice of place of residence may be restricted if necessary health professionals are not available as needed or if the health professionals living in the neighbourhood did not want to do that type of work, and health professionals, regardless of where they live, also have the right to choose to work or not to work and choose what type of work they wish to do.

That is the end of the written brief. Basically, I would suggest that I think, because we are talking about stable situations, the legislation needs to be looked at very carefully so we are not running into situations where we are being inappropriate in the type of care or level of care giver we are asking to provide this care. I would be happy to respond to any questions.

The Chair: Thank you for your very thoughtful presentation. I am going to ask the clerk to give you a copy of the Hansard which addressed the concerns you have raised regarding disabled persons and personal care. It is on the record, but Mr Wessenger is going to respond at this time as well.

Mr Wessenger: I would also like to thank you for your very thoughtful presentation, and I would like to assure you that the minister and previous ministers have indicated that there would be an exemption for attendant care givers by regulation under the legislation. That commitment is there, and certainly the committee is very much aware of the need to have that exemption.

I wish to ask you a particular question. You indicated you want certain safeguards with respect to the provision of care for children. I wonder if you might elaborate on that, when you say there should be ongoing supervision by health care professionals. First, I ask what you envisage by that and, second, do you envisage this with respect to children only and not to adults?


Ms Hamilton: I would suggest that any health care professional, specifically in nursing, who is going in and teaching someone how to do something is not going to simply say the individual can do it and back out of the situation unless she feels comfortable with the level of understanding of the individual and ability to give the care properly.

I would suggest if I am dealing with children, in many instances, and again I emphasize that I am talking about children with stable medical problems to a large extent, the responsibility for flagging changes in the child's conditions lands with the parents anyway, and the parents supposedly have contacts with physicians or whatever. When it comes to a child in a stable condition, you are not going to have a situation where somebody wandering in once a month and looking at the child is going to pick anything up. As for a child in an unstable condition, then I would not want to be talking about this anyhow when we are talking about attendants. I think I danced around the point.

Mr Hope: Good politician.

Ms Hamilton: I would suggest that in any situation, if someone is going in teaching, there should be some sort of care plan or description of what is being taught to that individual. It should be documented by the health care professional that, "I went in and taught that." If that is available, then there should be some safeguard in there.

Mr Beer: I would like to ask which date of Hansard was provided to the witness. Is that yesterday's?

The Chair: No, the one from the first week when Ms Bohnen --

Mr Beer: All right.

The Chair: I will give you a copy of it.

Mr Beer: I think it would be useful as well if perhaps yesterday's Hansard -- the reason I mention that is that there was a group of people concerned about this issue who got together with the Ministry of Community and Social Services, the Ontario Medical Association and others. They came up with a draft amendment to the legislation which I think would be of interest to you and your colleagues in looking at how they approach this. I know there is a provision for regulation, but I think that would be useful as well, particularly as we go forward with long-term care and so on; all of these programs are going to have a greater need for this.

I wanted to come back to the issue of supervision. What are the particular problems you see here? You mentioned the school, Montreal River, and so on. I imagine you are involved in some of the planning around how long-term care is going to be provided here in the long run. What are some of the particular training issues and problems you see, and how are you trying to approach them in the north?

Ms Hamilton: In isolated communities, to a large extent we depend very heavily on finding somebody to teach who is someone other than a registered nurse or a registered nursing assistant. Again, the issue becomes whether you can find somebody who can be trained and whether, once the training has happened, you feel comfortable with their ability to carry it out appropriately. The third issue is of someone in that system, that individual who is the focus of the care, being able to flag when things are changing, for example, when it is no longer stable, when something else needs to be done.

We have a real problem because of the socioeconomic situation, especially here in Algoma. People are leaving the district. Those people are taking, in most instances, their wives, who are the nurses, the whatever.

As far as that is concerned right now, a lot of the supervision for any of the stuff that is happening out in the smaller communities is happening from the centre, that is, we try to dance very lightly and keep our finger very closely on any situation that we feel has the potential of somebody in there being at risk and needing closer supervision. Does that answer what you are asking?

Mr Beer: Yes, you have a list.

Mr Martin: My question has mostly been answered by the parliamentary assistant. It was to try to make a connection between the issue we have heard about so far on a number of occasions over the month around attendant care.

You brought to me a further concern of attendant care to children, because the assurance of quality of care was an issue. With the adult the adult himself can assure that he is getting the quality of care he needs; with children there is another concern there, and you also bring a perspective from the north and the unavailability of professionals. Will an exemption from this legislation in any way enhance your ability to do what you do best?

Ms Hamilton: Yes, it will, simply because if the professionals are not available I have no answers as to how we provide these services, therefore we have to have some exemptions so we can train somebody. But that puts the onus back on our system again to make sure supervision happens and that somebody is flagging things when kids are at risk or whatever, if for some reason there is nobody else in the system to flag it. For example, if the parents or the care givers who are with the children on an ongoing basis are not able to flag it, then the formal system of which I am a part is going to have to have something in there so we can catch those as well. I do not see that as a big problem, because generally the parents are good. They are going to pick up most of those sorts of things. But certainly some type of exemption is going to be necessary in order for us to deal with the kids out there, as I say, unless we are going to force people all to move into a centre somewhere and say, "I'm sorry, you can't live in Wawa" or wherever.

The Chair: I make the observation that the last statement by the presenter should be noted by the Ontario Pharmacists' Association, which is still here. I think it gives you a practical example of, and a response to, your question on why the exemption is in the public interest. Mr Hope, a question.

Mr Hope: Charles hit on it first, but I think it is important that we have a perspective from rural Ontario on the concerns you put forward around the disabled. I notice you keep using the word "flag." You are not saying "diagnose" but "flag" people. That is appropriate. You are not looking for a profession. With the papers out on long-term care, multi-year plan, trying to deinstitutionalize things, it is important that we have the non-Metropolitan Toronto view of things. I think it is important that you either communicate with the clerk or the clerk makes sure you get a copy, because the input would be valid. I just wanted to make that comment because Charles beat me to the question.

The Chair: Thank you for the comment. We appreciate that, Mr Hope.

I am going to do something we have not done before at this committee, with the support of the members. Our research assistant has available and is able to read into the record the amendment that was proposed yesterday at our hearings. With the permission of committee members I will ask him to read it into the record for all to hear again today, as that issue was raised.

Mr Gardner: This was presented yesterday by the Attendant Care Action Coalition. It was developed by them and a coalition of other groups and endorsed by quite a wide variety of groups. They want to add an amendment to subsection 26(2). It reads:

"To facilitate independent living, add a further subsection to read:

"`An act by a person which comes within paragraphs 5 or 6 is not a contravention of (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.'"

The Chair: Thank you very much. That will be available in written Hansard form over the course of hearings, but we thought it might be helpful for you to have it today.

Mr Hamilton: It makes me feel better.

The Chair: Did Hansard pick that up? I think that is important. The committee would want to hear how you felt about that. Thank you very much for your presentation.



The Chair: We ask the next presenters to come forward. The Ontario Association of Speech-Language Pathologists and Audiologists, Algoma chapter.

Mr Roy: Madam Chair and members of the committee, my name is Nelson Roy. As chairperson of the Algoma chapter of the Ontario Association of Speech-Language Pathologists and Audiologists and a practising speech-language pathologist, let me begin by saying that our members enthusiastically endorse the intent and goals of this legislation as well as the vast majority of its provisions. However, we believe additional clarification and requirements are needed. I will attempt to summarize and highlight these today.

As members of this committee, I am sure you are now painfully aware of our very serious concern regarding section 26, pertaining to the authorized act of diagnosis. Unfortunately, as the act now reads it negates the basic objective of our association. It places a double burden on an already overburdened health care system. It means that the professional who performs the assessment, analysis and interpretation, the recognized expert in the field, is unable to give comprehensive information to the patient or the patient's family. Without question, this clause requires and deserves further review. We echo the sentiments of our colleagues in other health care fields when we state that patients are best served by direct communications between themselves and their clinicians.

The remainder of OSLA's concerns centre around section 15, the issue of title restriction. This legislation aims to provide greater public protection through restriction of the title "speech-language pathologist." It will provide precise language for the public to distinguish between regulated and unregulated health care providers. For this reason, we believe it is essential to the protection of the public that the title "speech therapist" also be restricted. The title "speech therapist" is the historical designation for the profession of speech-language pathology. "Speech therapist" continues to be the professional title in use by many institutions such as school boards, government ministries, district health units and hospitals. Because the general public equates these two terms, there is a significant risk that persons seeking speech-language intervention would not necessarily differentiate between practitioners and their qualifications, thereby failing to make informed choices. Protection of this title protects the public from people who call themselves speech therapists but who are not qualified as speech-language pathologists.

In the same vein, we also urge that the phrase "in the course of care" in section 15 be removed as it further limits the protection of the public. As this clause now reads, unregulated people could use the titles as long as they were not practising in strictly defined health care fields. As you know, many speech-language pathologists and audiologists are employed outside traditional health care settings; they work in private practice, education, industry and social services. OSLA therefore believes that complete public health protection is provided through the protection of professional titles in these non-health care areas as well.

Finally, we wish to stress the need for a stronger holding-out clause. OSLA would like to see a much more comprehensive degree of title protection. We believe a stronger holding-out clause would prevent unqualified individuals from implying a level of training or regulation which they have not achieved. As the wording stands now, there is nothing to prevent an unqualified practitioner from advertising audiological services or speech-language pathology services.

We suggest that section 29.03 of the Health Professions Procedural Code in the report titled Striking a New Balance: A Blueprint for the Regulation of Ontario's Health Professions provides a less ambiguous definition of holding out. The information provided in this written submission highlights all the concerns I have expressed today. In addition, letters of support from various local interest groups are included for your review.

At this time, I would like to introduce Bruce Shaw, former president of OSLA and a practising audiologist from Sudbury, Ontario.

Mr Shaw: Starting off, we will change from a few of those issues to one I am sure the committee has been made well aware of over the last number of weeks with respect to the authorized act of the prescription of a personal hearing aid. Many of the concerns in the past presentations have focused on issues such as cost and access to services, as well as the risk-of-harm criteria that make that sufficient to become authorized.

Today I would like to touch briefly on some of those issues, because I think they have been well presented in the past. More important at this time is to really try to clarify what the basic outcome of the legislation is, and separating this basic outcome from the assistive devices program policies surrounding the provision of hearing aids. Historically there have been difficulties, even among professions providing services, on making that differentiation, and we would really like to focus on that today.

The cost concerns and risk-of-harm concerns were presented to this committee in London by a colleague of mine named Brian Field. The cost concerns, specifically with relation to OHIP billing for audiology services, were clarified, and system inefficiencies perhaps identified that now allow physician reimbursement for the supervision of audiologists.

As indicated to the committee at that time, the association is optimistic that, as one of the outcomes of this legislation, inefficiency in the system can be reduced, and that perhaps alternative funding mechanisms outside of traditional fee-for-service mechanisms be instituted that will allow funding for audiologists, not only in institutions but, most important, in community-based settings. That will be important particularly in the north, as I will allude to a little later.

The risk-of-harm criteria through instances of misdiagnosis, overamplification, particularly in the infant and child population, has also been identified to the committee. They have also heard a rationale that the prescription of a hearing aid is not a discrete act, that it is an outcome of assessment and diagnosis in taking into account a number of factors particular to each person. Again, those issues have been well clarified.

One issue I will deal with a little more specifically from a northern perspective is the issue concerning access to services. It is one that, having practised in the north for eight years now, I found of particular interest. I would just like to point out a couple of things to the committee concerning access. The picture that was painted back in 1988, when the assistive devices program was expanding to provide funding for adults and hearing aid services, was that access to these services by audiologists, particularly in non-metropolitan areas, was abysmal. There was really no good information available at that time to document one way or the other whether that was the case.

It was with great interest that we were finally able to get information through the assistive devices program, which was presented to a number of parties back in November 1990. Contrary to the description that was presented that audiologists are metropolitan-based creatures who do not venture into the north at all, and that alternative service providers in the form of non-audiologist authorizers are carrying the brunt of that service delivery, it was the exact opposite.

We saw a picture where, in the northern region, 72% of hearing aid authorizations were being conducted by audiologists. When we examined the non-audiologist authorizer profile, we found that almost three quarters of those authorizations were occurring in metropolitan areas. The reality of the situation seemed to be almost the reverse to what had been described.

One thing that was particularly perplexing to me was that despite apparent distribution of manpower and where services were provided, there was still an attempt on behalf of those service providers who are focused in metropolitan areas to suggest the most appropriate way to deal now with service shortages in rural areas -- perplexed, and perhaps, having dealt with that similar situation in management positions and so forth over the last seven or eight years, a little annoyed at times.


Service delivery in rural areas, particularly the north, faces very unique circumstances. We realize in the majority of health care fields that it will take special incentives to try to deal with those difficulties. What has been put forth as an option to address accessibility concerns is the distribution of non-audiologist personnel to provide authorizations for hearing aids.

That has been put forth as a cost-effective method as well. I cannot tell you how strongly I object to that from a functional standpoint. I have grave difficulties with the rationale that it is cost-effective. In a health care system that is overburdened, I fail to see the rationale of how training a one-dimensional professional and putting him in a rural setting, where the demands are multidimensional, will result in cost savings.

In satellite clinics that have been set up through the underserviced areas program -- and Elinor is well aware of those in Manitoulin Island, in Elliot Lake, to which I continue to provide service along with other audiologists -- the vast majority of the work done is assessment work. Authorizing hearing aids is a small portion of the work that is done. What makes it cost-effective to provide those services in those areas is the fact that you can combine the two. And in those instances, you can provide a professional who is going to be able to assess children, infants, multiple-handicapped individuals, and is not going to be restricted to the provision of services to strictly adults.

On that rationale, I always have difficulty with the justification of pointing to rural areas and saying here is the way to solve the manpower needs up there, utilizing personnel that are concentrated in and provide services in the metropolitan area, and do so effectively in those areas.

When I hear myself talking that way, though, the other thing that strikes me is that those concerns regarding access and cost become very tangential to what the intent of the legislation is. I would ask the committee to really focus on what the basic intent of that authorized act is and what the basic functional outcome is, and to separate that from ADP policy.

Very clearly, that prescribed act does no more than ensure that a hearing-impaired person, whether that person is eight months old, eight years old, 98 years old, whether that person has other physical disabilities or is a so-called standard case to deal with, will be seen by a physician or an audiologist in the province of Ontario. It does no more than that.

ADP policy comes into play and will determine who can authorize some of these devices. But that legislation does not prohibit any service delivery model from existing under ADP policy. All it does is entrench what I think is a very substantial hearing health care goal in ensuring that a hearing-impaired individual is seen by a physician or audiologist. It provides a very comprehensive health care umbrella under which a funding program can operate without its hands tied. It can look at alternative service delivery models, alternative personnel, if it so desires and if through the advisory committee, through that program, there is sufficient information to justify looking that way. That program also has to take into account regulating the business aspects of the industry, dealing with conflict of interest concerns that come up.

What I need to really stress to the committee, and what becomes very muddled and has historically been muddled in discussions concerning the legislative intent versus ADP policy, is that the two are separate. What we have here is a solid piece of legislation. It provides a good umbrella that says, if you are hearing-impaired, be seen by a physician or an audiologist if you need a hearing aid.

Under that, we have a program that provides funding, that, through an advisory committee to that program which has consumer representation, professional representation, can then determine in future years what the best way is to deal with access concerns, deal with cost issues, deal with training issues if alternative personnel are required.

I would urge the committee to try to focus and separate the two. What is in front of you now I feel is a very progressive piece of hearing health care legislation. It meets a hearing health care goal without tying anybody's hands in the delivery of service. There are very few programs or legislative intents that do that. I would urge the committee to seize the opportunity and ensure that clause and that authorized act remain in the legislation as it now is. Having said that, I now welcome any questions from the floor.

The Chair: Thank you very much for an articulate presentation before the committee. I think you have clarified for members many of the questions that have been raised previously, as well as your point of view and the point of view of your association. I would remind you that if there is additional information at any time, you can always submit in writing through our clerk. There are five minutes available for questions. Ms Haeck.

Ms Haeck: Thank you for an articulate presentation. Over the past four weeks we have heard from a number of consumers. One organization which made what I thought was a very interesting presentation was the Consumers' Association of Canada (Ontario), and it is stressing public information. As in some respects you did raise public awareness, particularly Mr Roy, I ask you what your association is looking at as a means of making the public much more aware of what either you as a speech-language pathologist, or Mr Shaw as an audiologist, really truly do.

Mr Shaw: Over the last couple of years, that has really been identified as a main goal of our association. Significant human and financial resources have been put to that end in developing what is basically a long-term public relations plan or public information plan. It has identified specific target groups who need to be made more aware of our services and what we do, defining them by physicians, other allied health care professionals, and the public. Strategies have been put in place with the help of consultant firms and the like to begin developing information packages. Certainly it is something that has been undertaken over the last couple of years and will continue to progress.

Mr Beer: Thank you for the presentation. Particularly in the audiology area, we have been struggling with that whole issue. For me, the way you place that in relationship between the ADP and this helps us tremendously.

I would like to go back to where you were outlining the results of the survey you did, because that really is an interesting result. You are based in Sudbury. How do you handle the outlying areas in terms of seeing patients and providing hearing devices and so on? How does that work for somebody who is in that outlying area?

Mr Shaw: That was a program that was developed initially, as I said, under the underserviced areas program. What it is focused on now are two communities in particular, Elliot Lake and Manitoulin Island. Elliot Lake is serviced approximately eight to nine days each month. I or another audiologist visit that community not only to provide dispensing services or repair services and the like, but also, as I was saying, the vast majority of time is still spent doing assessment work and counselling work and the like. There is a similar program on Manitoulin Island. I believe it is usually five or six days a month that we are down there providing similar services. The service is comprehensive in that it is a one-stop shopping service. That is one model of service that is available, and in this particular instance it is effective. That is the way the devices are provided, with repairs and follow-ups along a similar line.


Mr Owens: A question around access: You referred to diametrically opposing views. I share your annoyance, actually, at trying to get at what could be called the truth. My question is, where does the buck stop? Where do we draw the line?

Mr Shaw: On access, it is basically with a couple of things: in data that were verifiable on where people are getting services -- data were finally made available to us in October and November of last year, once the assistive devices program had been able to gather specifics from when your program was expanded. I think the picture outlined was as objective a picture as you are going to get. There is always confusion that arises because the authorizing of a hearing aid has been intermingled with what happens to get service for a hearing aid. The two are not related. The authorizing of a device has nothing to do with the follow-up servicing and so forth. Those services can still be provided in exactly the same fashion as they have been in the past. Where I think the confusion arises is in not being able to separate out some of those access concerns.

In all fairness, there are areas of the province that are underserviced and there probably always will be. It will be very incumbent upon the assistive devices program particularly and the advisory committee to that program to examine those areas and say, "How are we going to manpower-plan for those areas, utilizing audiologists" -- and of course my preference would be that -- "or other allied health personnel if necessary?" I think there is a good mechanism now in place for that. The current legislation does nothing to address immediate access. It gives us a full generation to manpower-plan by tracking that manpower now through the programming.

The Chair: Thank you very much once again for an excellent presentation.


The Chair: I would like to welcome the Ontario Nurses' Association, Local 46. You have 20 minutes for your presentation. I appreciate your being patient.

Mrs Olsen: May I introduce Karen Scott, a nurse practitioner from the Group Health Centre, and Elaine Craig, a home care co-ordinator.

Madam Chairman and members of the standing committee on social development, my name is Suzanne Olsen. I am a registered nurse, a member of the legislative committee of the Ontario Nurses' Association, and a staff nurse in the emergency department of the General Hospital in Sault Ste Marie. With me today are nurses employed by the Group Health Centre, Plummer Hospital, home care and the General Hospital in Sault Ste Marie.

Thank you for allowing me to present some major concerns we have as direct care givers concerning these three pieces of legislation, the Regulated Health Professions Act, the Nursing Act and the Midwifery Act. I understand that many health professionals, including nurses, have been part of a lengthy process of putting these pieces of legislation together. We applaud you for the intent of this legislation to protect the public from unqualified, incompetent and unfit health care providers.

After meeting with many staff nurses in this community, the general consenus is that there is much disappointment with this legislation as it pertains to nurses and their ability to practise safely and efficiently. This government has in the past been very supportive of nursing and its expanded role in the health care system. However, it appears to us that this legislation sets nurses back to a very subservient role.

We, as nurses in a northern community, do not have access to residents or supportive 24-hour physician staff and therefore have to rely on our educated decisions, which in the past have been backed up with supportive physician orders. But never before has there been the threat of a $25,000 fine or a six-month jail term that impedes our right to protect the patient's health by our decisions.

As you are aware, standing orders and protocols do not have the legal authority of written orders. They change constantly, and doctors often write orders for us after we have done the work. This works efficiently for patient safety, but not for our own. It is an entirely unsatisfactory way in which we have to work. Every day we are at risk of being reported to the college for exceeding our authority. How then do you expect us to continue to act in the best interests of the critically ill patient if you are putting us in the position of being faced with being imprisoned or fined for doing what is prudent for cautious patient care?

We as nurses working in the north are not given the benefit of 24-hour physician presence, so therefore we are expected to act quickly to intervene in life-threatening health situations. We have always placed patient safety first, but we now have to rethink our direction, as you put us in a very quasi-legal position in which to practise.

We are accountable to the College of Nurses of Ontario as professionals and we are also accountable to our employers as employees. Management nurses in your legislation should be fully accountable to the college and this should be explicitly stated in the Nursing Act. As you must be aware, there are cases where the courts have found that the college's jurisdiction extends only to nurses who perform hands-on care. We believe that if management nurses were accountable to the college for their policies and staffing, they would have to be much more realistic in their approach and this would reduce our double-jeopardy situation dramatically and would result in better protection for the patient.

I would now like to address the controlled acts. One of the areas of concern to myself and other staff nurses is the use of the phrase "on the order of a qualified person" which appears in two of the authorized acts for nursing. Restricting the activities of nurses by requiring an order for all controlled acts is detrimental to the public in that it will not coincide with efficient and safe patient care. If, however, these acts are to be restricted to qualified persons, I would hope that this group of persons would be as large as possible.

From my understanding, as it stands now some nurses, prescribed persons, will be allowed to write their own orders for two controlled acts: (1) performing a prescribed procedure below the dermis or mucous membrane and (2) putting an instrument, hand or finger beyond certain points of the body. These nurses will be selected by the council of the College of Nurses of Ontario, and I would suggest that it would greatly improve patient care if this group of prescribed persons were made as large as possible.

Controlled act 1, "communicating to the individual or his or her personal representative a conclusion identifying a disease, disorder or dysfunction as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the conclusion": This is not a controlled act listed for nurses and thus creates great concern among nurses. If it is not a controlled act for nurses, how will we continue to act in our present capacity as health teachers? On a daily basis we answer questions posed to us by patients who are under a great deal of stress, given the fact that they are anxious concerning their disease. If we are unable to discuss their illness, how will we obtain consents for surgery and continue with nursing diagnosis?

As you know, nursing diagnosis is a practice that is widely accepted all over North America. Many consents for surgery are obtained by nurses after initial examination by a physician and before sedation. This will not be allowed under the new legislation, as nurses will no longer be able to discuss medical diagnosis with patients. Because consents are not legal after the sedation, these same patients will have to remain in pain until the surgeon explains their diagnosis and ensuing procedure to them. Because of the time element, a great deal of time this happens immediately before surgery, and we as nurses do not find this acceptable.

Staff nurses spend a great deal of time giving patients pre-op teaching, prenatal care and discharge and home care planning. How then can we continue to discuss any matters concerning their diagnosis? Nurses spend 24 hours a day with their patients; physicians spend minutes per day with their patients. How then can we protect their rights? A fast explanation of a disease by a physician leads to many questions, to which we as care givers feel the public has a right to answers.

On many occasions receiving health information in a timely manner is imperative for the maintenance of the health and life of our patients. We as nurses do not conceivably feel that we should determine the medical diagnosis, but we would be wrong, however, to deny that we must have the right to draw conclusions using nursing diagnosis and to feel free to answer our patients' reasonable questions. Therefore, the communication of a dysfunction needs to be a controlled act for nurses, or you, ladies and gentlemen, will be tying our hands and driving more of us away from our profession.

When I first entered nursing in the late 1960s, it was unheard of to answer any patient questions relating to disease. We have come a long way in 20 years. We have maintained our confidence through continuing education and we have accepted the role of patient advocate, but without this as a controlled act for nurses, we will be forced to be quiet once more. May I stress that I do not feel that this is the intent of your legislation. Please do not ignore our skills and experience by denying us the right to do more controlled acts independently.

Controlled act 5, "administering a substance by injection or inhalation": This is a controlled act listed for nurses, but on the order of a qualified person. The amendment to this controlled act in the Nursing Act, paragraph 4(1)2 changed "on the order of a qualified person" to "on the order of a member of the College of Physicians and Surgeons of Ontario." This will create great problems for nurse practitioners working at an advanced level in this community. I strongly question the reason for amending this section.

Controlled act 12, "managing labour or conducting the delivery of a baby": After discussion with many nurses, I have been asked to emphasize just how important it is to include managing labour as a controlled act for nursing. We as nurses do not oppose midwifery, but we do feel that midwives must be nurses, especially if they are employed in a labour area that is managing difficult labours. The scope of practice of midwives overlaps the scope of practice of nursing. It is not logical to feel that there are enough trained midwives to take over every labour and delivery area in Ontario. How then will the obstetrical departments continue to function if this is not a controlled act for nurses?

Nurses currently employed and practising in these areas clearly manage labour, and in many cases in the north they deliver the babies when the physician does not arrive in a timely manner. Managing labour is included in the basic educational program for nursing. Managing labour envelops below the dermis or mucous membrane or beyond body orifices and non-intrusive actions. Because intrusive interventions are regulated by other controlled acts, I assumed that managing labour would be the care, support and assessment of the mother and foetus and the recognition, prevention and intervention in a labour crisis. If this assumption is true, it would be very important for the safe care of the mother and foetus to include managing labour as an authorized act for nursing. May I suggest that nurses as well as midwives and physicians should be able to manage labour. We in fact already do this and it overlaps the scope of practice, and this should be recognized.


The specific recommendations I would make after consultation with my colleagues are:

1. That prescribed persons who will be selected by the council of the college of nurses be made as large a group as possible;

2. That nurse administrators, educators and researchers should be fully accountable to the College of Nurses of Ontario and this should be explicitly stated in the Nursing Act;

3. That the first controlled act must differentiate between medical and other types of diagnosis, medical diagnosis being limited to doctors, but nurses and other health professionals should be able to communicate their diagnosis to their patients; and,

4. That nurses, as well as midwives and doctors, should be able to manage labour.

In closing, I would urge you not to overlook the valuable source of human resources that you have existing in the nursing profession. Our aspiration for the health care system in Ontario is that it can remain one of the best health care systems available for the people of Ontario. We appreciate that costs are soaring. However, we feel that compromising the quality of health care is not acceptable and we are willing to do whatever is possible to ensure that the health care system remains as it is today. We hope to be considered as a valuable source of input into the future decisions that directly impact on patient care and safety.

The Chair: Thank you very much for your presentation. A comment first from the parliamentary assistant, Mr Wessenger.

Mr Wessenger: Thank you for your thoughtful presentation, but I would like to indicate that certainly in our opinion there is nothing in the legislation that prevents you from discussing a diagnosis with a patient. I would also like to indicate that the whole question of assessment is not covered as a controlled act, and also the communication and discussion of assessment, again, is permitted to you as health professionals. It is not a controlled act.

I also would like to indicate with respect to the question of managing labour that we understand that is dealt with as a delegated act, so I understand you would be able to continue to do that as a delegated act.

Mr Beer: I have a couple of questions, one in terms of the managing of labour. I ask the parliamentary assistant -- and I would appreciate your thoughts on that -- what the reason was for having that as a delegated act as opposed to its being in the act itself. What is the rationale for that?

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

Mr Burrows: It is unfortunate that legal counsel is not here today. My understanding is simply that there are valid reasons. I wonder if it would be possible to raise that question with legal counsel on September 16.

Mr Beer: I will do that. We will follow up on that one and see if we can get a clearer answer.

The question around the nurse administrators, the educators and the researchers has come up in a number of the presentations. What you see is that because they are in effect managing what you do, they should carry the same responsibility you would have to carry before the college if there was any disciplinary measure. What is their status right now?

Mrs Olsen: As far as I understand, in cases they have not been held accountable; it has been the individual nurse. We are placed in a position, through staffing for instance, that if an administrator or a nurse-manager, who is part of middle management, decides, when we ask for help, say, in the emergency department because of an extra workload, that it is not necessary and something happens on that particular shift that endangers the life of somebody, then we are actually accountable as professionals before the college but he or she is not held with the same responsibility.

Mr Beer: Would you agree that if they were covered by the law that there could be instances where both of you might be held accountable?

Mrs Olsen: Absolutely.

Mr Beer: You just want to see that they are there as well.

Mr Martin: Because I am from Sault Ste Marie, I just wanted to say that I have had the privilege of having a nurse practitioner look at me, and also in the delivery room. However, my question is around the non-inclusion of nurse-managers in the college. I do not understand that. Maybe you could expand on that a little more for me, how that would impact on your ability to operate as a nurse.

Mrs Olsen: As a nurse, I am accountable to the college for the things I do in my everyday practice, but managers are not doing direct patient care. They are providing the service only in that they are staffing their particular departments. They are not there 24 hours a day; they are there only from 8 to 4. We are practising 24 hours a day and we do not have the same resource on certain shifts.

It just seems that if they leave us in a position where our practice can get into trouble, they are not as accountable as we are. We are there doing the work. They are at home, not worrying that we are understaffed, that we are trying to take care of four different things where we should be doing only one.

If they were accountable for staffing, they would have to have the proper number of people to care for the patients, whereas they can kind of wash their hands of it and say, "Cope." That is something we hear an awful lot, "Just cope; we know you can handle it." Sometimes that puts people in jeopardy. That puts people in a position where they are not going to get proper care.

Mr J. Wilson: I very much appreciated the brief. It was a very good job of articulating the views. We have heard some of them before. I am particularly interested in your comment that this government has a good track record with nurses. I would simply comment that they have zero track record with nurses. They have not been the government long enough to have a track record, but perhaps you are referring to their statements in opposition. They are now discovering that being a government is not as easy it looks. But I will ask a question.

Mr Hope: It is about time.

Mr J. Wilson: Well, these things keep creeping into these briefs and I cannot understand it. Having said that, perhaps you can give us a better feel of what a nursing diagnosis is versus a medical diagnosis.

Mrs Olsen: We use all sorts of tools to determine nursing diagnosis. We have assessment forms we fill out. When someone is admitted to the hospital, we have a two-page form that asks various health questions that physicians would probably ask in their initial assessment, but they seem to refer to our nursing diagnosis to determine some of the symptoms of their patients, after the fact. They depend on us to spend a lot more time with these people, questioning them on their health habits, on what they do to prevent disease. They do not have the time. A lot of times their physical assessment is very different from what our nursing assessment is. Then we discuss together why they made a certain medical diagnosis versus why we feel there are other things that might be bothering this person.


Mr J. Wilson: Has the association sought a legal opinion on whether it would be prohibited to bring a number of things under the scope of nursing diagnosis because of the controlled acts?

Mrs Olsen: I believe they have done some looking into some things legally, but I cannot hope to answer for the association. I am only a nurse. I am concerned as a staff nurse. I do represent, partially, the Ontario Nurses' Association, but my scope of practice is not directed by them. I am responsible for myself as a professional and to my patients -- most of all to the protection of the patients in the north.

We do not deal, in the north, with southern Ontario medicine, where you have people around all the time. I work in a very busy emergency department. In this city, we have one doctor on call for 15 physicians, between two hospitals, for 75% of the day. They are not there when people walk through the door having a heart attack. They depend on us to start all sorts of things. We start the IVs. We order the blood work. We have everything done by the time they come. We stick them on the monitor and realize before they have even arrived that they are in a lot of trouble.

We have always done that. I am not saying we have even protocols that say, yes, we can do an invasive action like starting an IV, but we do it and we get coverage from these physicians. But when you are threatening us with being fined and imprisoned, we are not going to feel quite as safe working on our diagnosis.

As an emergency nurse who has worked for 20 years, I can look at a monitor and know that somebody is infarcting. I do not have to wait until the physician walks through the door and says: "Start everything. Do the blood work. Do the ECG." I do that and I do that because I care for the person who is lying there on the table. Time is of the essence. We do not have a doctor there all the time.

Personally, I will probably continue in the same practice, but it is going to make me a little bit nervous if I think I can be reported for overstepping my authority, because really I do not have authority to start all those invasive actions. But we have been doing it for years, and it is necessary for the safety of the patients up here.

The Chair: I have a very short supplementary to the statement you just made. Are you saying that in your hospital there is no hospital protocol for managing of emergency procedures?

Mrs Olsen: You can say "protocol for managing emergency procedures." There is a blanket protocol. A nurse on the IV team can institute an intravenous, but we do not have standing orders from every physician. We have standing orders from cardiologists, but now that the general hospital does not have a cardiology department, those standing orders are quasi-legal. They are legal in that if you work in a cardiac unit you can start all this stuff. We get blanket orders, but we really do not have anything that says: "Yes, Suzanne, you can take the blood work. You can do the cardiac workup." We get it covered. We have never had any trouble with the physicians saying, "You shouldn't have done it."

Well, no, I should not say that. We have had trouble with physicians saying: "What do you think you're doing? I didn't order that." We just basically ignore them and say, "This is our protocol." They do not fight us on it.

But we have never been threatened before with being fined for doing this stuff. We have physicians who come from southern Ontario who cannot believe all the things we do, but we have done it because there is a need there, because there is not somebody there to say, "Do it."

Mr Owens: I want to follow up on my colleague's question with respect to nurse practitioners. I wish you folks had been a little more detailed on exactly what impact this legislation may have on nurse practitioners. As Sault Ste Marie is a relatively more urban centre, again relative to Beardmore or Pickle Lake, how do you perceive this legislation impacting on what nurse practitioners are able to do?

Mrs Scott: I can answer that. Nurse practitioners in Sault Ste Marie basically are doing physicians' jobs. We have booked patients. We diagnose. We treat. All of these orders are countersigned following the fact, not pre-empted. We have a protocol on things we can and cannot do, but all of our delegated acts are countersigned afterwards.

We feel this legislation has not opened up to allow us to do the things we are doing, and that we should be part of that delegated act. You are allowing it for midwives but you have totally ignored the nurses. People are looking for a different type of health care. I hear it every day in my practice: "You listen to me. You hear what I am saying." With this act, you are going to take that away from them.

The Chair: Thank you for an excellent presentation. I know you have answered some questions for the committee that have been lingering. Today is the last day of our hearings and we really appreciate hearing from you. I would remind you and all other presenters that there is an opportunity to communicate further with the committee in writing during the course of our deliberations if you feel there is any additional information that would be helpful to us. Thank you again.


The Chair: I would like to call next the Family Services Centre. You have 20 minutes for your presentation.

Mr Rivard: My name is David Rivard, executive director of the Family Services Centre. I may not take the whole 20 minutes allotted. I was listening to the previous presenter, who identified herself only as a nurse. I guess I identify myself only as a social worker.

As a preamble, part of the concern you may have come across in other communities is the fact that social work has not been included as a part of Bill 43, and certainly that is initially a problem that the social work profession sees as a major difficulty. Particularly within many of the health settings, social workers play a most significant part in the whole health care team, as do nurses and other professionals. Undoubtedly, without any kind of legislation to protect the practice of social work, individuals who work in our employ are placed in much jeopardy. I will basically use that as a preamble and get into some of the key things I wanted to mention.

Who are we as an organization? We are not necessarily considered a health care service, but if you look at the definition of health care, it would in fact, in my mind, include agencies that are providing what we will call mental health services. Locally, the family service agency is a non-profit social service organization committed to strengthening and enhancing family life, and a large number of the programs that we provide fall into that category of mental health. Some of the programs we provide are funded directly by and under the auspices of the Ministry of Health.

Some of the client population groups we deal with, as well, are individuals who have been through the health care system, most notably those who are survivors of abuse, particularly sexual abuse and wife abuse. In fact, when you look at the research involved with that, approximately 80% of these individuals have had contact with a physician prior to coming to a social service agency. Part of the difficulty has been the improper diagnosis of these individuals and giving them a psychiatric diagnosis when that was not necessarily the issue they were dealing with. So we see many of these people who have been through medical, psychiatric settings and are now showing up within social service organizations and who have been improperly diagnosed. In fact, 80% of the client group we deal with currently falls into this category of being survivors or victims of domestic violence and sexual abuse.

The other major category we deal with are those, particularly youth, who are struggling with problems around drugs and alcohol. Again, many of these young people, as you know, unfortunately end up going into the American system and often getting diagnosed and so on and spending large sums of money. Again, we would want to see more of that being put into our province.

Other groups are the developmentally handicapped adults, many of whom, as well, are deinstitutionalized and are now moving back to the community. They are suffering from a variety of problems and disorders, and we have a program that deals with really helping them to reintegrate to community life.

One of the final groups is what is called the stage 1 young offenders. These would be people 12 to 15 years of age who have been through the court system and are now what is called post-disposition. Our service would provide some counselling and support for them within the community.

The majority of staff employed by our organization would be deemed social workers: addiction counsellors, graduates of community college and university in child care, social sciences and a variety of other degrees. All of our staff are trained to complete what is called a psychosocial assessment, which really looks at the psychological and social, environmental makeup of the individual, and, as well, to conjointly share that assessment, or "diagnosis" if you wish, with the client directly. Again, there is that whole essence of being involved directly in reporting to the clients the nature of the problems they are experiencing. So that is a little something of who we are as an organization.


What are some of the concerns we have? Certainly, up front we want to support the intent of Bill 43 and really see it as an excellent piece of legislation. However, one of the gravest errors was not to include a profession which has been struggling for years to be recognized by the legislators as a profession, and that is the profession of social work.

It is unfortunate that we are the only province now in Canada that has no particular legislation to protect the public from persons who will call themselves social workers who do not have any specific training and so on. In the absence of legislation, this leaves, in my mind, people in our employ who in essence can call themselves social workers in some amount of risk of being prosecuted.

We have as an organization supported the need for specific legislation. Mr Beer will know from his position in previous governments that it was supported, basically, to go ahead with a social work act. We would really encourage this committee to talk to the current government to say, yes, there is a need to proceed with legislation to protect the public. Whether that be a specific social work act or an omnibus social services act that would include a number of other quasi-professions, certainly it is important to move ahead with that.

As an organization, one of the clauses we would be specifically concerned about is the one that is referred to as the diagnosis clause. My concern in reading this particular clause is that it may hamper individuals within our organization from making what we call a psychosocial assessment or a specific diagnosis as to the nature of the difficulties the client is presenting to our organization, if that would prohibit our staff from completing their job functions.

In turn, one of your other subsections points specifically to the fact that employers and boards and so on, organizations that employ these unregulated practitioners, may in fact be in a position of possibly ending up in litigation.

Those are, from our perspective, some of the primary concerns, particularly around this whole issue of diagnosis: who is allowed to make a diagnosis and what kind of implications that will have on an organization that is currently employing staff who are not regulated.

What are the solutions? One of the primary solutions that would, I think, assist in the whole process is to proceed with a social services or social work act which will incorporate those professions currently not listed in Bill 43.

There is an employment base of approximately 10,000 professional social workers in Ontario, and a little over 25% of those social workers work directly in the health care setting. Again, under this present bill, there is no protection for these individuals who do actively participate on the health care team. In fact, many of them, as with nurses, are often the first individuals to share with a patient or client the whole nature of the diagnosis and the problems that the individual is dealing with. So I will be waiting to hear from you whether you feel the current bill expands or hampers the ability of these health care professionals to in fact deal directly with patients or clients.

The whole issue of the communication around the diagnosis or assessment -- I am referring to point 2: Should this really, then, be inclusive to all other sections of the legislation, not just those involved in the controlled acts? I am aware that the Ontario Association of Professional Social Workers, in conjunction with the Ontario College of Certified Social Workers, made a presentation and also asked your committee to look at that option. If you are going to include this for certain segments, why not include it for all within the legislation?

When we look at definitions such as "disease," "disorder" and "dysfunction," again, I think those clearly have to be defined. Many of the health care practitioners, social workers in particular, tend to shy away from using terminology such as "disease." If you are going to use "disease," "disorder" and "dysfunction," I think it is only appropriate that those be clearly defined.

Fourth, until legislation can be brought forward to really regulate professions currently not included, every consideration must be given not to prevent organizations such as ours and other social service agencies from practising professions which are recognized -- they may not be recognized in legislation, but are recognized locally and at the provincial and national levels -- due to the fear of prosecution. Again, I know this is a concern that has been brought to your attention previously.

It is our hope as an organization that some of the issues we have discussed today, along with many of the issues brought forward by our colleagues across the province, will be listened to by your committee, and in any way if they can be adopted into legislation, we would appreciate that.

Mr Hope: Under your solutions to the problems, you indicate a social worker act. We have had presentations, both in support of a social worker act and against a social worker act. Dealing with this legislation we see a lot --

The Chair: The social work act is not before the committee at this time.

Mr Hope: I know, but it is part of his solution as a recommendation to the committee and point 1 of his brief. With the issue of diagnosis -- I know you make reference to making it clear under "disease," "disorder" and "dysfunction" -- would it be appropriate for "disease" and "disorder" to be deleted under the social work part of it so that you can communicate?

Mr Rivard: Certainly, as I mentioned previously, social workers would shy away from using that type of terminology. Often, though, if you are working within a health care setting, you would have no choice but to communicate that to a client or a patient. Under this current bill, there is no opportunity for social work to participate. That is the grave error I was concerned about. If there is an opportunity to include that, I would recommend it. If not, there may have to be a decision to look at some other piece of legislation that would protect the public, because the whole intent of this legislation, from my reading, is the protection of the public.

Mr Beer: I would like to follow up on the terms "disease," "disorder" and "dysfunction." If the word "dysfunction" were taken out of paragraph 26(2)1, in terms of what social workers are doing would that alleviate the problems you see around that diagnosis clause? I appreciate the other question around the social work act, and that may come about, but certainly this is going to be dealt with first. But is that the term which for the social work practitioners is the biggest problem with this?

Mr Rivard: I would not say that is the only term, necessarily. I think the three terms together cause some difficulty for social workers. We think of "disease" as much more a medical terminology but, as well, I think you can broaden that to say a community can be diseased, if we look at our own community being economically affected. Again, whatever terminology you are going to use has to be clearly defined, because we all have our own interpretation.

Mr Sola: You said something in your preamble that disturbs me greatly, and I hope I heard wrong or misinterpreted what you said. I think you said that of your client group, 80% are misdiagnosed. I wonder if you would elaborate on that, because that is very disturbing to me.

Mr Rivard: From our own practical experience, with 80% of the client groups we are dealing with being victims or survivors of domestic abuse and sexual abuse, a large portion of these individuals have been into the health care system and have been given a psychiatric diagnosis which in retrospect may not necessarily have fit the condition that person was experiencing at the time. They may have been manifesting certain behaviours and a diagnosis was placed on that. Part of the difficulty now is that these people are coming forward and saying: "I was a victim of sexual abuse within my family of origin. I wasn't at the time able to talk about it, but that was the secret I was keeping within. I may have been manifesting certain behaviours and from that a diagnosis was made." The person may have been put into a psychiatric facility. A lot of these people are now coming out and saying, "I didn't really have psychiatric problems, but I was put into that particular institution, so maybe I was inappropriately diagnosed."

The Chair: Thank you very much for your clarification and your presentation. We appreciate your appearing before the committee today, and I know you are aware that you can continue to communicate with the committee in writing over the course of our deliberations.

Mr J. Wilson: Madam Chair, I have a request for information from the parliamentary assistant. I believe it is on September 16 or 17 that we are meeting with ministry officials. Could we add to that list, if we have not done so already, the Attorney General's office? I know there are officials over there who have given comment in the past on this legislation and we would like the opportunity to address some concerns with them.

The Chair: The request is noted.



The Chair: I call next Tom Hendrie. You have 10 minutes for your presentation.

Mr Hendrie: Thank you, Madam Chair. As practising medical laboratory technologists working in the hospitals of Sault Ste Marie, we are pleased to have this opportunity to address this committee and we hope our comments will be helpful in the committee's consideration of Bill 43 and companion legislation, Bill 44 to Bill 64. We are specifically interested, of course, in Bill 53, related to medical laboratory technology.

Our interest in this legislation is heightened by the fact that one of us was chairperson of a special committee of the Ontario Society of Medical Technologists back in the early 1980s whose deliberations and representations enabled the OSMT to mount a successful lobby in the Ontario Legislature, which we felt was a contributing factor to the decision to conduct a Health Professions Legislation Review.

Ten years later we are on the verge of having appropriate legislation enacted, and as private citizens we maybe should be concerned that it has taken so long and that the legislative wheels turn so slowly. As professionals, however, we are confident that the necessary research and fact-gathering has been very thoroughly carried out and we have a piece of legislation which is acceptable to the professions concerned, which truly benefits the citizens of Ontario -- although, from what I have heard in the last half-hour, we could go on talking about it for another 10 years.

Anyway, we are very pleased that we will soon be forming a college of medical laboratory technologists to set standards for the practice of our profession in Ontario, and will charge the profession with the responsibility of ensuring these standards are upheld. We are pleased that our leaders have been able to show the profession is ready for this responsibility and we wish to assure you that the rank and file medical laboratory technologists is ready, able and enthusiastically willing to assume this responsibility.

We feel that the legislation can only enhance Ontario's reputation as having one of the best health care systems anywhere. We feel this reputation is deserved and pray the standards can be maintained in spite of the present federal government's new approach to funding.

Concerned professions as represented by Interhealth were asked by Elinor Caplan -- I did not realize when I wrote this that she was chairing this session today -- that the legislation should move forward in spite of imperfections. A unanimous "aye" was given as answer to this question and everybody was very happy.

Now I would like to bring the committee's attention to some points which we see as imperfections and express the hope that they can be dealt with later.

1. The minister's proposed amendment recommending the inclusion of a controlled act permitting medical laboratory technologists to obtain the blood sample for testing with the addition of a subsection 3(1): "In the course of engaging in the practice of medical laboratory technology, a member is authorized, subject to restrictions on his or her certificate of registration, to take blood samples from veins or by skin pricking."

We feel it is strange that this is the only controlled act considered necessary for inclusion in this bill. It may be that the committee, mostly being lay people, feels that invasive procedures using needles were considered the only medical laboratory technology activity which was potentially hazardous to the laboratory services users, that is, the patients who come to us.

The legislators and the public need to know that there are dozens, perhaps even more, of acts performed exclusively by medical laboratory technologists which, if not done exactly right, can result in serious injury or death. The most obvious of these potentially hazardous procedures is perhaps testing and matching of blood for transfusion. This task is carried out exclusively by our profession and needs a thorough knowledge of blood transfusion theory and technique along with considerable dexterous skills, which often have to be called upon in highly stressful situations. There is no room for error, and serious error can result in what could arguably be called wrongful death.

Many other tests we do concern monitoring levels of drugs, ie, digoxin, when the attending physician needs to know the blood levels so he can prescribe dosage and avoid calamitous overdosing. The technologist performing those analyses has great responsibility, and mistakes can cause very severe harm to the patient.

I could go through a whole litany of these situations. As to listing them in the Medical Laboratory Technology Act, it could be argued that all of these tests should be designated as such.

We also have a concern, a lesser concern, I have to admit, about the practice of medical laboratory technology in unlicensed facilities, for example, in doctors' offices. Doctors' office testing, though presently limited, is exempted from control of the director of laboratory licensing by authority of regulation 845 under the Laboratory and Specimen Collection Centre Licensing Act of Ontario when performing certain simple tests. We feel that doctors should not delegate this testing to personnel who may not be regulated by the proposed new college under this legislation. We are not saying this kind of thing is happening at present, but we realize there is a potential. We would hope these concerns can be appropriately dealt with in the regulations under the act.

Thank you for this meeting. We look forward to a speedy implementation of the said acts and wish your committee success in its final deliberations and recommendations

Ms Haeck: Thank you very much for providing us with a very interesting presentation. I do want to get some clarification at this point, through the parliamentary assistant, some comments from ministry staff. Mr Hendrie does make mention of the Laboratory and Specimen Collection Centre Licensing Act. Are there certain of these procedures which the medical lab technologists would be performing that are controlled by other pieces of legislation, say something in a hospital setting? Particularly, why limit to just the blood collection? Are there criteria for inclusion that maybe those other acts did not meet under the whole process of looking at the Regulated Health Professions Act?


Mr Burrows: Again, unfortunately legal counsel is not here; I am not an expert on the law. However, there are various controlled acts in this package that are controlled by other pieces of legislation; for example, X-ray under the Healing Arts Radiation Protection Act, and in the case of activities performed by many people in the institutional sector, other pieces of legislation, the Public Hospitals Act, and in this case Laboratory and Specimen Collection Centre Licensing Act.

With respect to the specific amendment put in by the minister for discussion, it was concluded that this act was not dealt with by other criteria being applied. The review, having as one of its criteria for selection whether or not other legislation did satisfactorily control the activity, and the ministry concluded that a specific situation with respect to the common drawing of blood by lab techs should be covered by a specific controlled act, so that was put in.

In the case of the others, the evidence presented to the review and the evidence presented to the ministry since by the provincial associations on behalf of technologists, did not convince of the need to mention the specific acts. Either they were controlled by other legislation, or they were done in a way, for example, that they were either uncommon and could be dealt with by delegation, or they were done commonly but they were done in the presence of another professional who was accountable, because the person was right there. There were various reasons such as that.

The Chair: Thank you for your presentation today. If there is additional information that you think would be helpful to the committee, please feel free to communicate with us in writing through our clerk.

Ms Haeck: Supplementary to my question, I wonder if we could be provided with a series of those acts, those other pieces of legislations that impact on the RHPA and some of those groups, and maybe some of the criteria as information for all.

The Chair: On the days of the 16th and 17th of September, through the ministry presentations, I think there will be a full presentation on which other pieces of legislation will require amendment as a result of this legislation.

Ms Haeck: Very good. I appreciate that.


The Chair: I call next Joyce Isbitsky. You have 10 minutes for your presentation.

Dr Isbitsky: I will try to talk fast. I have written out my stuff because I get a little nervous. I am not used to talking in front of committees. I will read fast, and I will try to leave some time for questions.

Thank you for this opportunity to comment on the Regulated Health Professions Act and the Psychology Act.

My name is Dr Joyce Isbitsky. I am a registered psychologist in independent practice based in Sault Ste Marie. I am also the director of the midnorthern region of the OPA, the Ontario Psychological Association, and in that capacity I represent about 35 members in Sault Ste Marie, Sudbury and North Bay, as well as a number of smaller northern communities.

First, I support the position expressed in submissions by the OPA and OBEP, Ontario Board of Examiners in Psychology, and by my local colleagues earlier this morning. As you know, the primary concern relates to the removal of all restrictions on the terms "psychology" and "psychological."

Second, I believe the adoption of the recommendations offered by OPA and OBEP would allow the praiseworthy objectives of the legislation to be realized without compromising the needs of the north. As it stands, I fear the proposed legislation will retard rather than promote the north's continuing struggle to guarantee its residents standards of health care on a par with the rest of the province.

It is no secret that accessibility of professional services, health care and otherwise, is severely limited in northern communities. There is neither a sufficient number nor range of practitioners to enable the delivery of comprehensive services. The services we do have are often geographically inaccessible or tied up in long waiting lists. Psychological services are no exception, with no more than 2% of psychologists employed outside the large provincial centres in North Bay, Sudbury and Thunder Bay. It is extremely difficult to attract and retain qualified professionals because of professional isolation, lack of opportunities for professional development, inadequate program resources, and, let's face it, lousy weather.

Those involved in the delivery of psychological services who wish to become psychologists must leave the north in order to do so. Because of the scarcity of qualified practitioners, there is a tendency to make do here with unregulated persons unable to deliver the level or range of care available in more populated areas.

Recent conversations I have had with department heads reveal that in the north job requirements are often downgraded or watered down once it appears that advertised positions will otherwise remain vacant indefinitely. The scene is set for a proliferation of practitioners who have not met minimum standards of practice, conduct, education and training.

That, unhappily, is where it is at in the north.

It follows that northerners have to be especially vigilant if they are to counter the possibility of harm. In fact, the opposite is true. Many northerners are ill-equipped to make informed choices in seeking health care and other professional services. Why is this so?

Northerners, especially those in smaller and more remote communities, have little access to accurate information about available services. They are not likely to have had exposure to psychologists, or other regulated professionals for that matter, or to sources of good advice such as teaching hospital departments of psychology, university graduate programs in psychology, or regulatory and voluntary professional associations, such as OPA and OBEP.

Let me illustrate. A client employed by a government ministry was referred to me by her physician. The ministry employee assistance program manager advised me that other psychologists were already available to ministry employees on an immediate basis. She was misinformed. The so-called psychologists were actually unregulated crisis workers.

Another example: The director of a local health centre assured me that the centre employed a psychologist. Again, the individual in question was an unregulated provider. I think this addresses your question about the burden being on the employer. It may be on the employer, but it does not mean it is working. Again, the individual in question was an unregulated provider.

Why should we expect the average Joe Northerner -- I hope nobody is named Joe -- to be better informed than these individuals in key positions within the health care system who do not know what a psychologist is and is not?

In failing to limit the descriptors "psychology" and "psychological," the proposed legislation will just add to this confusion, thereby increasing the potential for harm. Restrictions on the use of professional titles and descriptors is one way to ensure that service providers are accurately identified.

Earlier, Deborah Brooks stressed the dire need for qualified and accountable practitioners in the schools, given the risk for serious and lasting harm to children. Presently, Sault Ste Marie has not a single psychologist in either the public or separate system. Efforts to attract regulated psychologists to northern school boards would be hampered if school personnel were free to represent themselves as providers of psychological services.

Finally, issues of supervision and training -- we touched on this earlier -- are critical in the north. Arranging supervision can be very complicated here because there are often long distances to travel and few psychologists to act as supervisors. Despite this, the efforts of psychologists and subdoctoral ancillary psychology personnel to make the system work are impressive, thereby ensuring uniform standards of practice across the province and lowering the potential for harm. As such, I applaud the recent tabling of a memorandum of agreement between OPA, OBEP and the Ontario Association of Consultants, Counsellors, Psychometrists and Psychotherapists, OACCPP, which would seek provisions to recognize and regulate the many high-quality MA-level providers within the Regulated Health Professions Act.

Any questions?

Mr J. Wilson: Your colleagues this morning indicated they thought that the PhD issue and the MA issue were perhaps separate. I will give you a hint: Much of the thinking of the colleagues on this committee is that they are one issue, and a very important issue. It has been discussed for a number of years and we have finally seen a memorandum of understanding or agreement between the two parties.

We have had testimony, from I think some northerners who testified before us in another part of the province, saying there are a number of MA-level practitioners practising almost totally independently in parts of northern Ontario and that they seldom see a PhD or a psychologist to check their work. What has your experience been?

Dr Isbitsky: I think the problem is not as significant when you have MA-level people working where there are psychologists around to supervise. There is a danger when you have people out in the field practising independently who do not have contact with people who can act as supervisors. As it stands now, we do make impressive attempts to connect with the supervisor. Does that answer the question at all?

Mr J. Wilson: Yes. My concern is that we not put those people who are currently practising at the MA level out of business, because we have had testimony that they are providing a good service.

Dr Isbitsky: As I understand, one of the things OPA has been struggling to do over the years with less response from the ministry than I guess they would have liked, was to establish some kind of qualifying PsychD program for MA-level practitioners who have been out. If you have somebody who has been out practising for 20 years, obviously you cannot discount that experience. There needs to be some way of upgrading them with respect to the current theoretical developments in the field, some of the conceptual developments, so that they are then regulated and licensed to practise as a PsychD. It is a type of doctorate in psychology that would be granted.

To simply say that as there are not enough psychologists around to supervise, we will therefore dispense with supervision, I think the risk there is --


Mr J. Wilson: That is not what I was implying. I was stating that we have had testimony that there is very limited supervision in some areas of the province now.

Dr Isbitsky: That is basically what I am saying, that what the north needs is to attract and retain more regulated practitioners.

Mr Beer: Thank you for the examples in your brief, which did address the question I placed earlier, and those are very helpful.

I think you mentioned in your brief that neither board of education has a psychologist on staff. I believe one of the concerns that psychologists have is that school boards will hire people with other kinds of training, and that is where some of this title comes in, a "psychological consultant" or something of that nature. What is the experience you have of whom school boards or other organizations hire to provide what, in your view, is advice that should be provided by a trained psychologist?

Dr Isbitsky: I would like to turn that over to my colleagues who work more directly within the educational field. I am in clinical practice and I do not have direct involvement. Perhaps Alan can take that one.

Dr Gelmych: Currently there are people employed by both school boards who call themselves teacher diagnosticians. Usually these are teachers who have specific training in test administration; this does not mean they have specific training in test interpretation. These people are often asked to diagnose learning disabilities, for instance, to give those results back to parents and to organize a specific type of treatment response. That is a problem.

Mr Martin: Going off on a tangent, some of the tension of the north, certainly from my experience of having lived here for a while, is around the question of professionals providing services versus self-help groups and communities healing themselves of some of the social disease that sometimes creep in. I wonder if this legislation puts the focus so much on the professionalization of service that it may impact on the ability of a community to do those things through self-help operations which it has actually developed out of necessity over the years.

Dr Isbitsky: I do not always see self-help groups as springing up because there are not the practitioners. Even when you have the regulated practitioners there is a role for self-help groups. There is a range of mental health services that can be helpful to people. It may be that at one time a person will choose to go to a psychologist, but also be referred to a self-help group to get some additional support.

I do not see that restricting the terms "psychology" and "psychological" would in any way stop self-help groups from doing their work. But I still think it is important for the consumer to be able to identify: "This is a self-help group. The people I'm going to be working with are lay people with no specific training, but only that such as I may have as an average person." They may have survived a similar experience and in that way can be very helpful, but they have not studied a particular body of knowledge and had supervised training in application of the science of psychology. I think that in no way interferes with the ability of self-help groups to convene.

Mr Martin: To follow up on that -- maybe it is a little different again: I think it is part of the whole package; there are many people in communities in the north who do excellent mental health work because they are caring and have a way about them that is supportive, as people work through some problems. To set up a standard of academic achievement before you can actually practise sometimes inhibits the participation of those people in the profession, because to get an MA or a PhD is such an awesome task and is not always achievable by those who might be best in the field. Can you comment?

Dr Isbitsky: You have to weigh the disadvantages of maybe eliminating some people who are very good but who do not have the academic qualifications and who, with some of the programs we should have, could be brought up to par. There is the danger of eliminating some good people in the service of protecting the public from a whole other bunch of people who may not be good, who may not be supportive and caring, may not have met minimum standards of training.

I think what you are doing is guaranteeing a minimal standard with the title "psychology" and "psychologists" and "psychological." That does not mean the other people are not free to practise; they are free to practise. They are not regulated, and perhaps they should attempt to become regulated.

I think what we are trying to do is broaden the scope of who is able to practise within a regulated framework. It is not meant to ostracize or exclude people. I do not see it that way. There is a place for those people.

The Chair: I ask the committee's consent to ask a couple of questions myself at this point. We can extend the time. I have three questions that could be answered, I think, simply with yes and no answers that might let you know what I have heard from the committee and clarify some of the points. In fact, I would appreciate yes or no answers if you could do that.

Dr Isbitsky: Psychologists very rarely do.

The Chair: This is around the issue of access to services. Would you agree that people who hold master's degrees in psychology provide psychological services?

Dr Isbitsky: A qualified yes.

The Chair: You agree that they have been providing those services in the employ of the provincial and the federal government since this process began in 1982?

Dr Isbitsky: Again, a qualified yes.

The Chair: Why qualified?

Dr Isbitsky: Because it is going to depend on how you define the whole area of psychological services. Psychometrists are able to do psych testing, which is a psychological service. However, they are not, at this point, able to completely interpret and take responsibility for our psychological report.

The Chair: But they do in the employ of the provincial or federal government?

Dr Isbitsky: I do not really know for sure.

Dr Gelmych: Under the direction of psychologists.

The Chair: The next question I have follows on that. Do you believe it is the role of the self-governing profession to establish the requirements for entry to practice, or do you believe that should be the responsibility of the government?

Dr Isbitsky: Ideally, that is something that should be reached jointly. I mean, they should not be at odds, I would think.

The Chair: Why would you call yourself a self-regulating profession if you want the government to set the standards for entry to practice?

Dr Isbitsky: We do already have in place an act, which we have had for 30 years, that has set the standards for the practice of psychology.

The Chair: And which excludes the master's degrees in psychology.

Dr Isbitsky: But as I understand, there is an agreement that has been tabled to look at that issue, and it is an issue that has been looked at by the associations for a while.

The Chair: The last question is, we have heard that in this agreement they want an additional 18 months to discuss and come to terms with the entry to practice issue. What would make you assume this would be resolved within the next 18 months, as it has not been resolved in the last 10 years?


Dr Isbitsky: It took this committee a long time to get the Regulated Health Professions Act going. You cannot do these things overnight. But I think 18 months is a time frame. It is not indefinite; it is close enough that we have to really get to work.

Dr Gelmych: Most other provinces and states do have an agreement whereby both doctoral-level and non-doctoral-level practitioners have a scope of practice that in some ways overlaps, but is consistent with something that meets both parties' agreement.

Dr Isbitsky: In other words, there are models available for how to do that.

The Chair: Thank you very much. That is the end of my questions. I appreciate your coming before the committee today. I appreciate the committee allowing me to put those questions on the record.


The Chair: I now call OPSEU, the last presenters for this morning. You have 20 minutes for your presentation.

Mr Reid: I thank you very much for letting us have the opportunity to address you this morning. With great pleasure, I will introduce the members of my committee. Connie White is a charts technologist in chemistry from Laurentian Hospital in Sudbury. Frank Pezzutto is a charts technologist in histology at Civic Hospital in North Bay. I am an executive board member with OPSEU and I am also a respiratory therapist at Victoria Hospital in London. Amanie Oakley will be taking you through our presentation this morning; she is a registered technologist in biochemistry from Wellesley Hospital in Toronto. Without further ado, I will turn it over to Amanie.

Ms Oakley: It says "good afternoon," but I guess it is still good morning. OPSEU is pleased to have the opportunity to address the standing committee on social development to discuss the implications of Bill 43, the Regulated Health Professions Act. As a union, we represent 10,000 workers and many health care disciplines across the province and we, of course, have considerable interest in this legislation.

OPSEU has recognized for years that the health care workers are a dedicated bunch. We do deserve formal recognition as such, and for this reason OPSEU is pleased that through this piece of legislation these workers will receive the esteem to which they are entitled. There are, however, weaknesses in this legislation which we are respectfully bringing to your attention.

In a previous presentation to this committee, OPSEU voiced concern over the issue of union representation on the soon-to-be-formed colleges and the fact that its members will be barred from the health professions board and the minister's advisory council. That presentation focused on our concerns about disciplinary issues and the missing principles of natural justice. For anyone who missed it, that discussion is recorded in Hansard.

Today we will address the double-barrelled issue related to union representation, and that is the silence on the issue of grandfathering and the lack of distinctions on title protection. As an aside, we will also briefly address our concerns with the performance of controlled acts.

The future of some OPSEU members, primarily laboratory technologists, hangs in limbo because the legislation is silent on grandfathering. Likewise, audiologists, occupational therapists and dietitians, most of whom have formal educational qualifications, may be harmed because there are few title restrictions and, with the exception of audiologists, no jurisdiction over relevant controlled acts. Although these issues are very closely connected, we will address each individually.

The sole issue of grandfathering may affect anywhere from 5% to 10% of OPSEU health care workers, and thus it is an issue which requires closer scrutiny as a job security issue. By excluding a grandfather clause from this legislation, the government is implicitly questioning the fitness of our most experienced members to practise their profession. Laboratory technologists, the most affected group, have experienced technological and other workplace developments first hand. Yet these people who know their workplaces and their work so well may become victims of a change in values, a change which favours formal academic qualifications over experience. The extent to which they may become victims is severe: They may lose their careers.

A more offensive implication of the government's blind eye towards including a grandfather clause is the suggestion that it is the health care worker and not the system and not the administrators who are ultimately responsible for patient misadventure. This is not the case. Lab errors are infrequent. In quality assurance audits in the laboratory of a local 350-bed hospital, only five incidents were reported in the past year, and of these five only one involved a letter of discipline. This sound record is the rule and not the exception in labs around the province. This clearly indicates that these health care workers are competent and deserve the protection of a grandfather clause.

This is not the first time in Ontario's history that health care workers have been subject to this type of professional review. In 1964, the Radiological Technicians Act was amended to formalize the regulatory body and to define credentials for radiological technicians. These legislative amendments included a grandfather clause which allowed all workers who had been practising in Ontario as a radiological technicians for a period of at least five years and who could pass examinations by the board to continue practising.

It is OPSEU's position that a grandfather clause which is laid out in legislation is more important in 1991 than it was in 1964. The workforce is better educated now than it was 27 years ago and formal educational qualifications are more valued now than they were then. The trend towards valuing academic credentials may now be worrisome. Nobody now knows who will be elected for or appointed to the council committees which are charged with making decisions about testing procedures, and whether they will be biased towards practitioners with more educational qualifications.

According to the legislation, the decisions regarding who qualifies for registration, and how they qualify, lies with the registration committee of the colleges. In OPSEU's opinion, there should be little question regarding who, in terms of current practitioners, are qualified to perform their jobs. As we have said, health care workers are generally a competent bunch. Given the recent crisis in health care, however, we may find ourselves in situations where underfunding stresses current human resources and forces a hand at errors.

Should someone who has been practising a profession for 10 or 20 years suddenly be told that his or her qualifications are not acceptable in Ontario and that the accumulated weight of his or her knowledge and experience is not considered as valuable as the diploma of a new graduate? Until the last few decades, the work done by our present-day laboratory staff was the domain of the physician. As the workload of the physician expanded, helpers were hired to ease some of the burden. Many of the individuals in today's hospitals in need of grandfathering protection entered the various fields when the professions were in their infancy. As with any growing process, rules were created and amended over time.

While policymakers fretted over requirements and guidelines, these people quietly mastered all the skills necessary to perform their jobs and helped train the newly emerged graduates of fledgling courses. With the maturing of these new graduates, the backbone of expertise provided by the original practitioners became less vital and, as with many other professions, educational requirements began to steal the limelight from hands-on experience.

As a future direction, demands for more stringent educational qualifications may be appropriate, but in dealing with such new professional areas -- as we are -- those individuals who have been competently practising for a number of years without officially sanctioned diplomas should be excluded from the proposed requirements.

The next area I would like to look at is title restrictions.

OPSEU has concerns about the use of job titles which may imply formal qualifications where none exist. If this government is sincere in its attempt to provide more options and protection to the public, we believe there should be restrictions on what people can call themselves. Perhaps the most glaring example of this is in the field of speech-language pathology. Under this legislation, the only protected title for a person in this field is "speech-language pathologist." Ironically, this is not the title which the public, or even the medical profession, is most familiar with. These professionals are more widely known as speech therapists. However, because "speech therapist" is not a protected title, anyone, regardless of qualifications, can call himself a speech therapist, go into business as such and mislead clients into believing he is properly qualified to manage their cases. Clearly, the public runs the risk of being misled and can pay a big price.


It is a further irony that these charlatans, provided they are not performing any controlled acts and provided they do not tag themselves with a restricted title, have less liability to their clients than do licensed professionals. Only a member of one of the college can be brought before its council on a complaint of professional misconduct and lose a licence, a job and a reputation. Where the professional in question is not performing any controlled acts, it becomes even more difficult to make the distinction between the two, because they both have the same scope of practice.

Let's take the example of dietitians. Presently, there are no controlled acts listed for dietitians. This leaves the door wide open for a person who does not have any of the educational requirements or years of experience in the field to call himself, for example, a nutritionist, and in so doing, clearly deceives the public as to his qualifications. If such a person provides poor advice to a client, he still cannot be brought before the regulatory body of dietitians to answer for his actions. OPSEU believes that the very public this legislation is meant to protect runs the risk of receiving a different type of service than they bargained for.

OPSEU believes it would better serve the public and the professions if the clause first adopted in the report by Alan Schwartz respecting title protection was put back in the legislation. This would make it illegal for any person to take or use any name, title or description implying or calculated to lead people to infer that the person is qualified or recognized by law as a member of the health profession. The public should not be expected to carefully research credentials of health care workers every time they have to seek treatment.

Many members have voiced concerns about subsection 26(1) and paragraph 26(2)1, which prevents them from "communicating to the individual or his or her personal representative a conclusion identifying a disease, disorder or dysfunction as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the conclusion."

Communicating with clients and their families is an integral part of the work done by many of our members. To disallow that would change the context within which most of our members work. This ban on communication would also be inefficient.

Speech-language pathologists and audiologists know better than physicians the source of communication disorders or dysfunctions. Physiotherapists know better than physicians the details of soft tissue damage following motor vehicle accidents. For these professionals to do a workup on a client, then refer the client back to the physician for diagnosis and have the physician send the client back for treatment is ludicrous. It also makes no sense that now, for the first time, physiotherapists can take clients without a physician's referral, but that same physiotherapist cannot give the client a diagnosis of his condition.

OPSEU is well aware that the government had no intention of creating inefficiencies by permitting assessments at all levels and restricting diagnosis. It is not our intention to harp on this, but we wish to make clear the fact that there are conflicting legal opinions on this issue. It is likely that at some point the distinction between an assessment and a diagnosis will be drawn, but it may be drawn at a considerable cost to some members.

It is quite clear that no bill can anticipate all its consequences when it is first drafted. However, over the past two weeks, OPSEU has presented some very well-thought-out and very serious concerns about these bills. We ask that you give them your fullest consideration.

Mr J. Wilson: I certainly sympathize with your comments surrounding grandfathering. My own mother was effectively shut out of the teaching profession for only having gone the normal school route rather than getting a degree when the PhDs took over the teaching even though she has taught for 30 years. I know first hand what that can do to one's salary and one's esteem.

I would ask the parliamentary assistant whether the government has given any consideration to the issue of grandfathering?

Mr Wessenger: I would like to indicate that we also are concerned about the question of grandfathering. The way, of course, we see that being dealt with is under the regulations made by the governing college with respect to the profession. It should be noted that those regulations will have to be vetted through the advisory committee before they are put into effect, and they also, of course, have to be approved by the Lieutenant Governor in Council. We see that through that procedure there would be definite protection. With respect to the whole question of grandfathering, we certainly want to see it dealt with in a fair manner; there is no intention to deprive qualified people of their right to practise in their profession.

Ms Oakley: Could I make a comment on that? I am curious why some cases have been specifically grandfathered, such as chiropodists and so on, and not these professions. It is of concern to us because -- I can fax you some of this information -- in magazine articles that have been written up interviewing members of our governing bodies, these people make it very clear that education is the be-all and end-all, and that you are not getting it in order to practise better or go up in salary or move forward, but that you should get your ART, for example, which is the next level up, for no other reason than just the sheer joy of it.

I would really wonder whether people like that could comprehend the dilemma faced by some people who have been practising in the field for 10 or 20 years and have to write an exam again when they have not seen a book or that kind of formal education for so long.

Mr Wessenger: I would like to have ministry staff respond to that as well.

Mr Burrows: Just two points: First, the regulations that will be proposed with respect to entry level will be proposed by the interim or transitional council as well, and government will be taking great care to ensure that the transitional council composition is composed fairly.

Second, with respect to grandfathering -- you mentioned chiropodists -- I would point out that in the case of groups such as osteopaths, chiropodists and so forth, these people are in fact already self-governing. There is a big difference between a self-governing profession -- one that is already established by statute and you are lifting it out of one statutory framework and putting it into another -- and granting self-governing status to a profession that has not been self-governing where such issues as entry to practice for this self-governing entity still needing to be addressed and vetted in a public way.

The Chair: A question, Mr Owens.

Mr Owens: I think parts 1, 2 and 3 of my questions with respect to grandfathering have been answered.

Mr J. Wilson: You can throw out that briefing note now, Steve.

Mr Owens: I found it rather astonishing to find out that I was turning a blind eye to this issue after asking, in several different venues, questions around this issue.

Anyway, approximately how many folks are we talking about?

Mr Reid: The numbers are probably very small. It is rather difficult. We have tried to find and extrapolate that type of information from the various societies that are around, but they do not keep those types of numbers themselves.

The group we are concerned with most is, as I said, in the laboratory technology. If we look at the history, about 20 years ago there was a great demand to recruit people into laboratory technology, into the different health care sectors, and what they did in that case was advertise outside of the country to places like the Philippines, Great Britain and other areas. They accepted people who came in with American qualifications, from the Philippines, and British qualifications, and also accepted people into the field with a BSc in related sciences. These people are long-term people. They have been working in the field for anywhere from 15 to 20 years and practising as recognized and qualified RTs. Those are the people we are concerned about.

Mr Owens: In terms of what happens in the private laboratories as opposed to hospital settings, is the grandfathering issue still applicable? Should we look at a separation between public and commercial, or should we continue to move forward with grandfathering medical technologists as a whole?

Ms Oakley: I think you are still going to have the same problem in private laboratories. I do not think they will be out of a job, but they may be using that as an excuse for having to pay them less to do the same work.


Mr Owens: In terms of quality assurance and ensuring that the bottom line is protected and the patients are getting the highest standards possible, salary is really a tertiary issue.

Ms Oakley: I have a personal situation going on right now at Wellesley similar to what you are asking about. I was approached by one of the directors of the lab and told that one of the people working in nuclear medicine is not registered here; she is telling me that when this legislation goes through she is going to have to get rid of this person. The person has been working 20 years. I said to her: "Have you had any problems with the person's performance? Is that why you are approaching me?" I was told, no, this is not a performance problem.

As Bob has said, a lot of the time we did experience a severe shortage. People were lured into this field, and now we are looking back and saying: "Maybe that wasn't the greatest idea. We'd better put more stringent standards." That is fine for the future, but if someone has a history of poor performance, that is going to be dealt with in another manner beyond what their credentials are.

Mr Beer: This is probably the sixth or seventh on grandfathering. It seems to me that one of the things it is important to recognize here, though -- it was commented on in a question -- is that with the new councils moving to set up standards and all that kind of thing, it is a much more public process. The kind of example you have just mentioned is clearly something, assuming that the person is competent and capable, that simply should not, indeed must not happen. I would hope that the very public way in which those standards would be set would protect against that, at the very least. As you mentioned before, those can be drawn to legislators' attention to deal with. I think it is not going to be a closed room where that will be done. It does not mean there will not be any problems, but it seems to me there is greater public protection.

On the first page where you are talking about grandfathering, would you see a program similar to the one that was done back in 1964 as being a fair way, that they would look at those who were going to be grandfathered and perhaps set certain time frames and/or some kind of tests? What did you have in mind in terms of how those people might be grandfathered?

Ms Oakley: It is not an inefficient way to do it. However, I have to question, since these people have not had any kind of performance problem, the need to do it again -- these people, and I feel for them, have been out of school for that entire length of time -- unless we had testing that was done specifically for the area they are working in.

I am registered as a technologist in five areas. However, I have only been out of it for five years, and I can tell you the fields I do not use every day are gone. And these people especially, because they often have been relegated to specialized tasks due to their lack of credentials, have been told, "Okay, you're going to take over this particular bench." They do not even know biochemistry -- but they may know the special tests in biochemistry. That is my concern.

The Chair: Thank you very much for your presentation. I would like to ask you one question that I asked the previous presenters, if it is all right with the committee. In a self-governing, self-regulatory framework such as this, in your view who should make the decisions on entry to practice and grandfathering, the government or the self-governing boards, councils, colleges?

Mr Reid: We agree with self-regulation as far as the different professions go, but because this is a legislative act coming down, forcing the hand of a number of the different health care professions, therefore, what we are asking in a number of our presentations is that with this legislation and the direction for self-governing the government take responsibility to make sure that the way this self-governing is set up is responsible to the people it is going to self-govern.

The Chair: Supplementary to that, the report on access to trades and professions identified that as a very specific issue, and I think it is of concern to everyone on this committee and all members of the Legislature to ensure that competent, qualified individuals have access to trades and professions, particularly those who chose this country for the opportunities it provides. It is one that I know legislators will be struggling with to make happen, and it is very difficult in a self-governing relationship to know how that should work. I appreciate your comments.

Mr Hope: That is why we need more lay people.

The Chair: That is one, but there is also the obligation and responsibility if you are going to have a level debate.

Mr Hope: So we need more laypeople.

The Chair: That is not necessarily the only answer.

The committee recessed at 1216.


The committee resumed at 1342.


The Chair: I would like to call first the Nutritional Consultants Organization of Canada. You have 20 minutes for your presentation and if you would, leave a few minutes at the end in case committee members have any questions. We have all received your written brief.

Dr Rowland: First of all we would like to offer our congratulations to the team that put this legislation together. We wholeheartedly support its intent, namely that of providing the public with free access to services of their choice, and regulating the practitioners accordingly. There are, however, some inconsistencies that work against the main purpose and actually deny consumers some of the safe health alternatives they now have.

I would like to tell you a little bit about who we are. The Nutritional Consultants Organization of Canada, or NCOC, is a voluntary non-profit association incorporated under the laws of Ontario. We have two classes of membership: first, associate members, people from the general public who are interested in nutrition; and we have a second class of membership, professional members, who are health care practitioners. I speak to you today on behalf of both classes of our members.

We would like to make it clear, in reading over the legislation, that we are not in violation of section 31. We do not falsely hold ourselves out to be a body which regulates, under statutory authority, individuals who provide health care. In all our literature we mention that we are a voluntary association. We do provide the title RNC, registered nutritional consultant, to our professional members who meet our academic and ethical standards for practice. This is entirely a voluntary thing and the title we use is not similar to any of those in the bills that are proposed.

Bill 43 will not change the way we practise. We will continue to operate legally as an unregulated health profession. As individuals we are free to do anything except that which is forbidden by law. We especially welcome the concept of controlled acts. It makes it very clear to us where the boundaries are. Provided we do not commit any controlled acts and provided we do not use any restricted titles, then we are legally free to assess and treat nutrition-related disorders.

Now, there are a few controlled acts that I would like to mention. One of them is paragraph 26(2)2, procedures on tissue below the dermis. Unless there is an exception stated somewhere that we have not found, this would wipe out the practice of acupuncture. It would give it to medical people who, for the most part, are not trained in acupuncture, never studied it, are unaware of its benefits and are incapable of providing it. Would this proposed section cut these people off, the ones who have been benefiting from acupuncture, or would it drive them into the hands of those who circumvent the law in order to provide a valuable health alternative not available elsewhere? We suggest that acupuncture be made an exception to this particular section.

Subparagraph 26(2)6vi, among a list of things, mentions that it is a controlled act to insert any instrument beyond the anal verge. Thus, administering colonic irrigations would become illegal if done by other than medical doctors or nurses, who may not be aware of the benefits of this kind of therapy and who would quite rightly consider the performance of it to be a waste of their considerable training. In Ontario there is quite a history, we understand, of individuals who assist others to cleanse their colons of accumulated filth which may be a contributing factor in certain disease processes. These people have been doing it for quite a time and, so far as we know, there is a fair safety record. In fact we do not know of any problems in terms of the safety record at all. If colonic irrigation is to be put into the hands of medical doctors and nurses, then it effectively denies the consumer access to it because it really is a waste of a practitioner's time to go back to school to become a registered nurse to do just this one thing; and the nurses, who are highly trained, have better uses for their skills.

Paragraph 26(2)(4) refers to spinal manipulation, and our concern is here as well that the chiropractors have this as a controlled act, but we do not understand how medical doctors can have this as a controlled act under their scope of practice. Spinal manipulation is not a subject that is taught in conventional medical schools. We understand of course that osteopaths are to be included in the Medicine Act, but what protection do individuals have against potential injury from spinal manipulations performed by doctors who, although legally permitted to perform them, have neither the training nor the skill to do so safely or effectively? That is our concern. The way it is worded, it is open-ended; medical doctors can do it.

Paragraph 26(2)(5) restricts administering any substance by inhalation. It would therefore prevent unauthorized practitioners from using therapies which rely on the inhalation of steam, dilute eucalyptus oil or the vapours or aromas of other harmless substances. We respectfully recommend that the wording of the paragraph be changed to read, "Administering any substance by injection or administering any drug by inhalation" where "drug" is defined according to the definition proposed under paragraph 26(2)(8).

Paragraph 26(2)(7) restricts certain forms of energy, but these are unspecified. Nowhere in the proposed regulations can we find any definition of the forms of energy which are proposed to be restricted. To be made into a law this way, it is like giving legislators a blank cheque to fill in the forms of energy later on. Obviously the administration of X-rays, gamma rays and the like need to be limited to qualified practitioners, but what about innocuous and subtle forms of energy such as magnetism and electroacupressure? We respectfully suggest that neither we nor our elected representatives can know what forms of energy are to be permitted or restricted unless they are specified in Bill 43 before it becomes law.

Paragraph 26(2)(8) defines a "drug"; it defines it according to clause 113(1)(d) of the Drug and Pharmacies Regulation Act, but to our knowledge there is no such act as yet. It has not received its first reading. Now if clause 113(1)(d) in the Drug and Pharmacies Regulation Act is identical to clause 113(1)(d) in the Health Disciplines Act -- Pharmacy, then we have no problem, but this needs to be spelled out.

Section 30 would restrict the title of "doctor" to chiropractors, optometrists, medical doctors, psychologists and dentists. Such restriction discriminates against holders of legally valid doctorates in other health care fields and against unregulated health professions which have just the same legal right to practise and are just as legally valid as those groups to be regulated by Bill 43. The title "doctor" was originally used for centuries as a term for a teacher or a learned person before we used it to describe medical and health care providers, so we have some questions. Would someone with a PhD in biochemistry, for example, who wrote a book on taking vitamins, not be allowed to call himself "doctor" because the book could be construed to be giving advice to individuals on their health care? Certainly individuals would rely on the things that were said in the book.

We would like to point out that legally valid doctorate degrees are awarded in health care fields in specialties other than the five listed in section 30, by legally valid institutions which have the legal right to award such degrees. Examples include doctor of naturopathy, doctor of acupuncture, doctor of homeopathy and doctor of philosophy degrees in such fields as biochemistry and nutrition. Those seeking health care have the right to know what qualifications and training a given practitioner may have in his or her field. One common way of doing this is for the practitioner to display his certificates or diplomas on the wall. Now if we have a practitioner who cannot legally call himself doctor but has to have a legal doctorate hanging on his wall, can he not refer to that? Can patients not refer to that? Is there some kind of restriction on freedom of speech? It is a fact that he has had this training, and the patient or client or participant has the right to know about this.

We respectfully recommend that section 30 be revised to the following, "No person shall use the title `doctor' in a fraudulent or misleading manner, or in any way that wrongly implies that said person has skills or authority which he or she does not in fact have." In this way, it seems to cut off all the conceivable abuses of the title without denying people the legal right to refer to the training they have had.


Section 3 of Bill 51, the Dietetics Act, which is mentioned in schedule 1 of Bill 43, says, "The practice of dietetics is the assessment of nutrition and nutritional conditions and the treatment and prevention of nutrition-related disorders by nutritional means." As such, we find it extremely misleading to the general public. It proclaims skills which dietitians do not have. It confuses the terms "dietetics" and "nutrition," which most assuredly are not the same. The main emphasis of dietetics is on mass feeding. Dietitians are responsible for the menus in hospitals, prisons and other institutions. Some are employed by food companies; some are also employed by community public health departments. According to an earlier submission by the Ontario Dietetic Association, only 5.6% of dietitians in Ontario are employed in private practice, and some of these work as self-employed consultants to food processing companies. Very few dietitians counsel individuals.

Dietetics is a narrow subcategory of the much broader field known as nutrition. Its emphasis is on measuring one's food intake in such terms as it adheres to the four food groups, counting calories and so on. It assumes that all people are the same. It does not take into account that each of us is biochemically unique, that our metabolisms differ, we absorb nutrients at different rates, we have different requirements and so on.

We respectfully suggest that individuals who seek the services of a dietitian for assessment of nutritional conditions and the treatment and prevention of nutrition-related disorders may be misled as to what to expect when actually consulting a dietitian. We respectfully recommend it would be a more accurate presentation of the truth to change the wording of section 3 of Bill 51 to, "The practice of dietetics is the assessment of diet and dietary conditions and the treatment and prevention of dietary-related disorders by dietary means."

In conclusion, I would like to say that our proposed amendments will strengthen Bill 43 by eliminating inconsistencies and inequities before it becomes law. To deal with them after the fact would be costly, ineffective and wasteful of health and human resources. Bill 43 has the potential to create a health care system that is second to none, giving consumers ready access to safe therapies of their own choosing. It has the potential to eliminate monopolistic practices in the health care field, thereby opening the door to both greater competition and greater co-operation in providing needed services.

One thing Bill 43 will do is protect alternative and complementary practitioners from the risk of being charged with practising medicine without a licence. Henceforth, entire professions are not to be licensed. Only specific acts deemed to be harmful if performed by untrained personnel are to be controlled. By avoiding all unauthorized acts, all practitioners from every health field can legally assess, treat and prevent disorders without fear of persecution. We predict that the favourable climate created by Bill 43 will place more emphasis on preventing diseases and less necessity on last ditch efforts to cure them once they have taken hold, with resultant savings in suffering, potential lives lost and health care costs. We sincerely hope that other provinces in Canada will enact legislation similar to Bill 43.

Mr Beer: First of all, I really do want to thank you for an excellent brief. We keep talking about the members of the committee having a steep learning curve about a lot of things that we do not know about. I think you have pointed to a number of issues, some of which have come up before, but a number which have not. I think it is fair to say -- and perhaps I have a question, but maybe later the parliamentary assistant could comment -- that some of the things such as acupuncture indeed will not be wiped out, that there is a process by which they will be exempted or regulated or somehow dealt with.

Dr Rowland: Will this include colonic therapy or just acupuncture?

Mr Beer: The only one I know of at the moment is acupuncture. I will put it as a question at this point. Are there any others on that list that specifically are going to be dealt with?

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

Mr Beer: It seemed to me it was acupuncture. I know spinal manipulation has been raised by the chiropractors. We have been looking at that. I thought there would be a process for forms of energy as well.

Mr Burrows: Yes. With respect to acupuncture, there is a specific commitment that there will be an exemption under the authority to grant exemptions. We expect that would resolve that problem. With respect to colonic therapy, I think this is subject to further discussion. Unfortunately, I was not present yesterday. There was a presenter on the subject, and I do not know what discussion took place with the committee or if any commitments were given; but you are absolutely right that a specific exemption would be necessary, and I expect the committee would be considering the evidence put before it. I would certainly agree that for low pressure, based on the evidence that I have seen, there is not much evidence of harm.

In the case of spinal manipulation, I think the health professions legislation review was convinced that this was a potentially hazardous procedure, but it is recognized that more than one profession does perform this act or some variation of this act. It is one of those areas where the extent of the manipulation really is an important factor. But I would point out that, under this legislation, all the health professions will be required to have mandatory quality assurance programs. One of the questions we expect to flow from that over time is that each college will say of its members, "Although we have this range of licensed acts, are all of our members capable of doing all of these things?" We expect a natural evolution here. But certainly there is no doubt that some physicians do spinal manipulation. I do not think there is any evidence to show that is particularly more hazardous than other practitioners performing it.

Mr Rowland: So the protection to the public will come through the college which regulates the physicians?

Mr Burrows: Yes, it will be up to the college to determine whether or not physicians are doing the right thing in that respect.

The Vice-Chair: Could I move on, since we have a fair number of people who would like to ask some questions. Mr Owens.

Mr Owens: I would like to find out a little more about the designation "registered nutritional consultant." How does that compare to the dietitian and what sort of functions would the RNC perform versus the dietitian, and where would you folks practise?

Mr Rowlands: Our professional members provide nutritional counselling services primarily to individuals. Most nutritional consultants are in private practice. Some work in conjunction with chiropractors, naturopaths; some, of course, with medical doctors and so on. Some work in conjunction with only the health food stores and so on, but primarily they counsel individuals.

The RNC certificate is simply something we, as a volunteer association, award to our members who have met our standards. We insist either on a bachelor's degree in holistic nutrition, which is quite different from dietetics, or its equivalent. If a person does not have a background that we consider important, then we suggest some courses they can take to make up the difference. We assess each person on his or her own merits. You are really asking two questions, you know, the certificates and the type of practice.

Mr Owens: Where would one obtain that bachelor of holistic nutrition, that type of education? Is it carried through the College of Naturopathy or is it in the States?

Mr Rowlands: All those who have bachelor of nutrition degrees get them in the United States. There are no colleges in Canada that offer that kind of thing exactly. We do, however, have some graduates from the University of Toronto, I think the University of Waterloo and the University of British Columbia, who have taken the mainstream nutrition degree programs and then have gone on to specialize and to do further study in what we consider to be holistic nutrition. Our effectiveness comes from varied backgrounds. As yet, there is no college in Canada that offers exactly the course we need.


Mr Hope: Just one question dealing with colonic therapy and your comments. Not being an expert myself on all those acts, could you elaborate a little bit more?

Dr Rowland: I have a copy of the present act, the Health Disciplines Act -- pharmacy. Clause 113(1)(d) defines a drug. It is quite a lengthy definition, which includes anything, and then it says "except, except, except" the things referred to in certain schedules. We have gone over it with a fine-tooth comb and this is great. What it is really regulating are controlled prescription kinds of drugs. But the act that is proposed, that is mentioned in Bill 43, is not in law yet, so we are assuming that this is going to be the identical definition. But is it? That is our concern.

Mr Wessenger: I think ministry staff can clarify that whole question about definition of drugs.

Mr Burrows: The existing definition and all other things pertaining to the regulation of pharmacies and drugs -- not pharmacists, because this legislation deals with professionals -- will be simply lifted out of the existing Health Disciplines Act and retitled. That is all this proposal does, so it is neutral on the question.

Dr Rowland: Great. That was our assumption. I just wanted it clarified.

Mr J. Wilson: Great clarification. I will have to get a copy of the Hansard.

Mr Johnson: A very quick question. With regard to "who we are," I see this organization was incorporated in 1983. There must be a companion organization, I am assuming, in the United States. I was just wondering -- this advisory board, are these people Americans or Canadians? I see Linus Pauling there. Would that be Linus C. Pauling, the physicist?

Mr Rowland: The twice Nobel laureate, yes, it is. There is no exact counterpart to our association in the United States, to our knowledge. There are two or three associations, some have come and gone, and we are not sure of the status of them. This is an independent Canadian organization. On the advisory board we have Dr Abram Hoffer, a noted Canadian; we have Jan de Vries, who is from Scotland; and the rest are from the US. These are people with whom we have developed associations and who have contributed significantly to the field of holistic nutrition.

The Chair: Thank you very much for your presentation. If there is additional information that you think would be helpful to the committee during our deliberations, please feel free to communicate with us in writing; just address it to our clerk.

Dr Rowland: Thank you. What deadline would we have, or have you decided?

The Chair: We expect the committee will be considering the bills, clause-by-clause, after the Legislature resumes, and that date is September 23. We will be likely, through the month of October, examining the bills during clause-by-clause debate. We cannot give you a time line exactly because it will depend on the numbers of hours required to do clause-by-clause.

Mr Hope: Co-operation.

The Chair: And Mr Hope mentions co-operation of committee members, which I am sure we will have. Thank you very much.


The Chair: I call the Ontario Secondary School Teachers' Federation, Sudbury branch, District 31. You have 20 minutes for your presentation.

Ms Peloso: Thank you, Madam Chairperson. I would like to thank the standing committee on social development for taking the time to obtain all this input from various areas of society regarding this legislation, especially in this hot weather. I am sure you would rather be anywhere else but here.

The Chair: We have had a warm welcome.

Ms Peloso: You have had a warm welcome in the Sault. You would have just as warm a welcome in Sudbury, I am sure.

I am Mary Ann Peloso and I am a speech and language pathologist. I am the secretary-treasurer of the professional student services bargaining unit of the Ontario Secondary School Teachers' Federation, District 31 in Sudbury. My colleague is Dr Brian Burtt, who is a psychologist, and he is the president of our professional student services branch of OSSTF.

We were quite excited about this opportunity to be able to present a brief together, being from two different professional backgrounds -- a psychologist and speech-language pathologist -- who sometimes can be at loggerheads, but in our instance we are not. We work quite well together in very collaborative system delivery models for our school board.

We applaud the principal aim of the Regulated Health Professions Act and related acts to ensure the protection of the public within the scope of the services provided under the auspices of the Ministry of Health. However, we represent professional groups who, although we have the same professional titles as our colleagues who work in health, work in a number of different ministry areas such as education and community and social services, as well as private practice. We have some questions and some concerns about how this legislation will impinge on our roles and positions in education.

This is particularly critical at this time when a lot of effort is being put forth by the provincial government to try to co-ordinate services among the different ministries. I point out Memorandum 81 as one of the pieces of legislation that is attempting to do this very thing, to facilitate health services being delivered within education.

Another recent document, Children First, in November 1990, addressed to the Minister of Community and Social Services, is really attempting to co-ordinate efforts for children across the different ministries. I will quote one of its recommendations found on page 59 of that document: "There must be a single major physical centre that operates as a hub of services for children within each community. Where possible, the school should be this centre for service provision."

And another quote from page 56 of its recommendations is: "The provincial government should promote models of service integration and collaboration that simplify access to service and rationalize the roles of our limited resource of trained specialized service providers." In northern Ontario this is certainly true, that we have very limited resources and we have to really be very careful how we make use of that limited pool and how we can facilitate their working together most effectively.

The sections of the legislation that we will be addressing in this brief, which we feel are likely to impinge upon our roles as effective professionals working in education, are the controlled acts section of Bill 43, section 30 that was referred to in your previous presentation and the restricted titles and representation of qualifications subsections of both Bill 44, for audiologists and speech-language pathologists, and Bill 63, for psychologists.

The one section that, as speech-language pathologists, we are most concerned about is the controlled acts, Bill 43, paragraph 26(2)1. The controlled act of communicating, which reads, "Communicating to the individual or his or her personal representative a conclusion identifying a disease, disorder or dysfunction..." etc, etc, is a controlled act that is proposed for psychologists and physicians, but not for speech-language pathologists.

We feel that not being able to communicate our findings -- since we are being legislated to be able to assess and to treat communication disorders but we are not being legislated to be able to communicate our findings -- will severely inhibit our ability to work as part of a multidisciplinary team in the educational setting.

Speech-language pathologists represent a body of knowledge and expertise that is important for the diagnosis of communication disorders. Speech-language pathologists are equal members of the multidisciplinary team serving children and adolescents in the school setting. Consequently they should be able to communicate their findings directly. To deny speech-language pathologists this role would very likely result in the downgrading and possible demise of this profession in Ontario.

We recommend that the act of communicating be included as a controlled act for speech-language pathologists. Specifying the conclusions to be communicated should prevent impinging on the professional responsibilities of psychologists or physicians.

Section 4 of Bill 44 should be revised to include, "In the course of engaging in the practice of speech-language pathology a member is authorized, subject to the terms, conditions and limitations imposed on his or her certification of registration, to communicate a conclusion identifying a communication disorder or dysfunction relating to articulation, voice, fluency, or language difficulties."

I will turn the floor over to my colleague, Dr Burtt.


Dr Burtt: I am going to speak to the subject of restricted titles and the representation of qualifications for our two professions. The problematic wording in subsection 15(1) of Bills 63 and 44, which apply to psychologists and speech-language pathologists, in our opinion is restriction of the title users to health care. Health care could be interpreted to apply to psychological, speech-language or audiological services supplied by professionals funded in some fashion by the Ministry of Health. For psychologists, health care might also be interpreted in the sense of mental health services without any consideration of funding of the provision of the services.

As outlined by the Ontario Board of Examiners in Psychology in a letter to Ms Cathy Fooks in April 1991, "health care" is a term that will certainly exclude many applied practices of psychologists. Most glaring examples, in the opinion of the Ontario Board of Examiners in Psychology, would be the practice of industrial or organizational psychology. It might very well turn out, though, that the practice of school psychology might be interpreted by the courts not to constitute health care.

The additional qualification of title restriction in subsection 15(2) of both Bills 44 and 63 also, at first glance, might suggest that the membership in the College of Psychologists of Ontario or the College of Audiologists and Speech-Language Pathologists of Ontario might act to naturally restrict title usage and consequently expand beyond the health care focus I was just alluding to into other obvious applications of these two professional fields. This could certainly diminish concerns such as ours. However, this additional qualification could be legally interpreted as being inconsistent with subsection 15(1), with subsection 15(1) possibly superseding subsection 15(2). We are certainly not lawyers in terms of the interpretation of such acts, but we do have this possible concern.

It is recognized that the stress on uniformity in the wording of the sections across the professional acts accompanying Bill 43, such as the one on title restriction, does hold appeal, the appeal being simplicity in this case. The focus of the bulk of professional services offered by different professions covered in the professional acts is likely what prompted the inclusion of the health care provision in subsection 15(1). However, applied psychology and speech-language pathology are by no means restricted to health care as are the majority of the other regulated health professions.

For instance, school psychologists, whom we are representing, account for approximately 15% of all psychologists practising in Ontario; I refer you to appendix A. Speech-language pathologists working for school boards constitute even a larger percentage, 27% of all speech-language pathologists employed in Ontario; I can refer you to appendix B. In addition to these professionals working in private practice or in industrial-commercial applications, they are employed under at least three ministries aside from the Ministry of Health, as Mary Ann was mentioning before, the three other ministries being Education, Community and Social Services, and Correctional Services.

Aside from the foregoing concerns relating to the restriction of title, psychologists and speech-language pathologists in general have a concern about the protection of title. Subsection 15(1) could be interpreted to mean that the restriction placed on the use of titles could permit unregulated practitioners with little or no training to hold themselves out as psychologists or speech-language pathologists as long as they did not provide service that could be interpreted as constituting health care.

Such a situation could ostensibly develop in the provision of school services, where a person not belonging to one of the colleges, or for that matter not possessing any training in these areas, could represent himself or herself as a school psychologist or speech-language pathologist. To the best of our knowledge, a definition of health care is not provided in Bill 43 to clarify this matter. Subsection 15(2) could also be interpreted as prohibiting individuals only from holding themselves out as members of these colleges. Current practices of distinctly holding oneself out as a provider of psychological or speech-language services could therefore be continued, such as using the title "psychologist," providing health care was not being provided or using descriptors in their titles with the "psycho" prefix, such titles as "psychological associate," "consultant in psychology" or "psychotherapist."

A limitation within title protection in subsection 15(1) of Bill 44 is the omission of the title "speech therapist." "Speech therapist" is a title that is used quite synonymously with "speech-language pathologist" in northern Ontario, so we do have a problem in terms of public perceptions of speech therapists.

The recommendations we are offering in relation to restricted titles and the representation of qualifications are:

First, the phrase "to provide, in Ontario, health care to individuals," in subsection 15(1) of both bills 44 and 63 should be amended to read "to provide services in Ontario" to make the title usage less restrictive. We are only referring here to psychologists and speech-language pathologists.

Second, the title "speech therapist" should be added to subsection 15(1) of Bill 44.

Third, the amended wording for subsection 15(2) of Bill 44 that is recommended by the Ontario Association of Speech-Language Pathologists and Audiologists, and has been outlined in the working document put forward by the committee working on the health professions, is also supported. That wording is, "No person other than a member shall take or use any name, title or description implying or calculated to lead people to infer that the person is qualified or recognized by law as an audiologist, speech-language pathologist or speech therapist."

Fourth, furthermore, the stance of the Ontario Board of Examiners in Psychology is that section 15 should be expanded to include another section to further protect the title of "psychologist" as necessary. This wording is, "No person other than a member shall use any designation or description incorporating the words `psychological' or `psychology,' a variation or abbreviation of them in the course of providing or offering to provide services in Ontario."

The last concern we all relate to refers to the restriction of the title "doctor," as we have heard in the previous presentation. We certainly have similar concerns in so far as people using the term "doctor" in an academic sense are concerned. The restriction of the title "doctor" is certainly a major source of concern to speech-language pathologists in the province. Section 30 of Bill 43 limits the use of the title "doctor" to five professional colleges, but speech-language pathologists are not covered in this listing.

Thus, speech-language pathologists or audiologists possessing a PhD would not be allowed to use the title in the provision of the services although his or her qualifications were at the same level of training as the psychologist who earns a doctorate degree. Since this is an earned academic title, the restriction of the title "doctor" in the provision of speech-language services is deemed to be discriminatory and cannot be justified. Members of the college of audiologists and speech-language pathologists who have earned a PhD should in fact be allowed to use the title "doctor." Our recommendation is that the college of audiologists and speech-language pathologists be added to the group of colleges in Bill 43 to be allowed to use the title "doctor."

In concluding, we as representatives of the professional school student services personnel of the Ontario Secondary School Teachers' Federation do strongly recommend the amelioration of concerns of the professions of psychology and speech-language pathology working in education relative to the impact of the Regulated Health Professions Act. The continuation of effective services for students with communication difficulties, for instance, would be hampered by not allowing speech-language pathologists to communicate their findings.

In a more general sense, protection of the public will be jeopardized if title protection is only applied to health care. The speech-language title is currently not being protected and the use of other terms implying other qualifications is allowed.


Mr Owens: Just a quick question after that rather thoughtful presentation: I am just wondering, should this committee agree to accept your recommendations, how would this benefit the kids and the families the kids come from?

Dr Burtt: Right now in the provision of our services we have to give, in a very general sense, considerable thought to the types of services we are providing students within our board. We are essentially accountable to parents and students through my current college, if you will, the Ontario Board of Examiners in Psychology. I am essentially being policed in my actions in my care in the school system. In that sense, I feel the optimal psychologically related services are being afforded to students.

We do have people who work for school systems at the current time who do hang out the prefix "psych" in their name, such as psychometrists, who are not supervised by a registered psychologist. I have personally seen a number of practices that have occurred in such cases that I certainly would like to have been able to correct. I have had no avenue to correct that, whereas if it were a peer, another psychologist, I would have been able to approach him as a peer, offer my counselling and, if that counselling had not been followed up, then taken the next course of action, which would have been reporting him through the Ontario Board of Examiners in Psychology.

Mr Owens: So what you are suggesting, then, is that these changes would ensure standards of practice and a level of quality assurance, again benefiting the kids and the families?

Dr Burtt: Yes, outside the provisions of health care, such as within the field of education.

Mr Beer: My question is also in the area of psychology. We have had a great number of presentations from speech-language pathologists, so I appreciate the issues you raise. I think those have become clearer, at least in my head. The question I would like to ask you follows on some of the discussion we had this morning with other psychologists. One of the questions has been that only PhDs are members of the college. Would part of the overall problem we are dealing with be helped if MAs could become part of the college and come in under the whole regulatory scheme? I wonder how you would answer that question and how that would affect particularly the provision of psychological services for schools.

Dr Burtt: I am not sure if it would be too complicated a system. We certainly have been considering the master's level of service provision in a regulated manner in some sense. We have been toying with the idea of whether it would be best, first of all, looking at this strictly in terms of titles, to consider them more as associates or as assistants, and incumbent upon this would be the amount of training and the amount of education that would be responsible to faithfully represent those sorts of titles. Second would be the amount of supervision that would be required by a psychologist. We are viewing this sort of relationship in a sense where we still do feel that a psychologist would be ultimately responsible in some sense.

In terms of regulation of master's level degrees, I am not sure exactly whether this could be furnished within Bill 63 as such, being addressed as an entity. I would have a lot less reservation about that than I would about such a profession or a capacity being represented under a different bill wherein they would essentially be treated in a truly autonomous fashion and would not be in some fashion accountable to psychologists.


The Chair: I call Michael Hamilton. You have 10 minutes for your presentation. Just for the information of committee members, Dr Hamilton is presently the chairman of the Sudbury district health council. He is not here in that capacity today, but I thought you might like to know that.

Dr Hamilton: Thank you, Madam Chair. It is a pleasure to see you again and to appear before you this afternoon. Welcome to the north on such a warm day. My name is Michael Hamilton. I am a native northerner. I am proud to be an Ontarian, and I think that we live in the best country in the world and have the best health care system in the world, and I would like you to know that we in the north are very appreciative of the services we have here.

I am here to address you on -- you will forgive me, I hope, for my candour; I will get right to the point as northerners often do -- two provisions, one regarding the Denturism Act, another regarding the Dental Hygiene Act. I should declare, first, that I have a conflict of interest in that I am a dentist, and I know we are all very interested in conflicts these days. However I am no longer in the general practice of dentistry, and I now make my living representing the dental public health interests of the population in midnorthern Ontario. I work at the health unit. My interest is not financial at all in this, and I would like you to know that. As Madam Chair has said, although I do represent the Manitoulin-Sudbury District Health Council in other ways, I am not here on behalf of the council to speak to you.

One of the guiding principles that Mr Schwartz used in 1982 in the legislative review with regard to the health professions was that consumers should have a freedom of choice within a range of safe options. That is something that is important for you as legislators to remember, that whatever transpires as a result must be safe for the consumer of those services. I do have some concerns with regard to those two acts.

I would like to go on record as being very supportive of the legislation. What this is all about in the health system is accountability to the public, and that is exactly what is being done with this legislation as it is proposed. We are making providers of health services more accountable to the public, and that is what we need to do and continue to do if we are going to improve services in the future.

I draw your attention to the second page of my submission, and I will get right to the point. Under the Denturism Act there is a proposal that denturists -- and I presume you know who denturists are by this stage; if you do not, please query me during the question period -- will be able to fit, dispense and order partial dentures. That is different from the present practice where they can make full dentures for people. Of course, the problem becomes one of the foundation for those partial dentures, because a partial denture is a denture where there are teeth remaining in the mouth.

The point that I would like to make to you is if indeed a person has not had a suitable assessment beforehand, an examination and a diagnosis, there is a risk to that person's dental health of having a partial denture placed. It is akin to constructing a new house on a foundation that has not been properly assessed or diagnosed, or, in northern terms, to sinking a mine shaft without really having a look at what is down below. It is costly in the long run, and in the short term it can be very, very dangerous.

The easiest solution to the problem is not to restrict denturists from making partial dentures. No one is saying that, and dentists certainly are not saying that. The solution, I believe, is to make sure that consumers have had adequate assessment examination and a diagnosis that a partial denture is the best treatment for that person at that particular time. I submit to you this would be one way you could protect the public interest.


Under the Dental Hygiene Act, dental hygienists have, for the last 25 years or so since dental hygienists have been trained in community colleges, been very effective members of the dental preventive team. I can tell you as a public health person that the dental public health in Ontario is among the best in the world. It is the best in Canada. I can tell you that 50% of our young adults, our teenagers now, have never had a cavity. That is something we can be very proud of. But if you think of our generation which is one step or two steps up from that we have many more problems.

Under the Dental Hygiene Act, there is a provision that dental hygienists would be able to establish independent practice. This has been tried in several states in the US, and frankly it has not worked. The reason it has not worked is that people realize services that could be provided in the independent hygiene practices are very limited. They are basically tooth cleaning. That is essentially why people would go to an independent hygienist.

The system is working very well, and I am somewhat worried about fragmenting the system more if we allow the independent practice of dental hygiene. In public health, I have eight hygienists who work not for me but with me in providing the best possible dental public health services in northeastern Ontario.

I submit that what we should be doing is looking at continuing that interplay and making sure that we do not allow the system to be fragmented any more. The current practice in public health is that hygienists can operate under the order, direction or supervision of a dentist. In fact, yesterday dental hygienists working for me were out at one of the seniors' homes up the street while I was back at the office downtown, working under my direction, independently, on their own, but making sure that what was being done for those patients in the homes was appropriate. That is the way the standard is now and I would be worried if it changed much and hygienists were able to go out and operate totally on their own, not taking into account medical conditions of patients and so on.

Those are the two concerns I have. I think probably a change of some of the wording would be all that would be required under the Denturism Act and under the Dental Hygiene Act. That is my submission to you. If there are any queries, my consultations are free. They always are in public health. I would be happy to try to answer them for you.

Mr J. Wilson: We certainly appreciate at this late stage in our hearings your sense of humour. You mention something that was not really the teeth of your presentation, but you mention that the public will be --

Dr Hamilton: Good line.

Mr J. Wilson: I had to write that one down.

The Chair: Hansard will strike that.

Mr J. Wilson: I am already a minority on this crew. You mention that the public will be better represented on professional councils. We have had some professionals appear before us, representing professions, indicating that they felt that, with the new requirement of just under 50% public representation, it may erode the principle of being a self-governing profession. Do you want to comment on that?

Dr Hamilton: To that I would say, so what?

Mr J. Wilson: I thought you would probably say that.

Dr Hamilton: Consumers are the ultimate beneficiaries of the services provided by the health care professions and if we do not have enough consumer input on our councils, then we are not going to get the kinds of services that people want to have. I think we have been remiss historically in not having more consumers on our councils. Certainly other councils -- the boards of health, the district health councils -- have always had consumers giving input. I would support that totally. We are here really as providers, but for the consumer.

Mr J. Wilson: I thought it had been interpreted by the courts that when you are doing supervision, or whatever the current terminology is -- for instance, your example of the dental hygienists being up the street -- you were supposed to be on the premises.

Dr Hamilton: No. In public health in designated spots -- I am not sure of the actual regulation, the number or anything -- it says "under the direction or supervision of a dentist," and "supervision" means physically on the site.

Mr J. Wilson: Right.

Dr Hamilton: But it says "direction" or "supervision," so that as long as I can show, as a dentist, that the hygienists who are working for me out in the field have had adequate training, know what they should be doing and can do and have a standard procedure, then there is no problem. The Royal College of Dental Surgeons has recognized that. Otherwise, we would never be able to have public health dental services because it would be physically and resource-wise impossible to have a dentist to screen schoolchildren, to go out into collective living centres and to hospitals, etc. We use auxiliaries. It is cheaper for the system and it also results in just as good service.

Mr Owens: Regarding persons having to have a dental examination prior to having a partial made, philosophically I do not have a problem with that. My only question is, how would you go about defraying the cost of that dental examination for a significantly large portion of our population, and seeming to grow every year?

Dr Hamilton: That is a hard one, and I am not sure how you can answer it. We do not want to milk the public purse any more and say that we will pay for an examination like that. I think probably what could be built in is some sort of a procedure code or a fee in the dental guides so that people would say, "We're coming in for an assessment because we're expecting to have a partial denture made"; something like that, and we would have some sort of a structure in place so that people would know that.

I am not sure about your second comment. I do not feel that there are that many millions or thousands of people who need partial dentures these days. Certainly, the standard of dental care 30 or 40 years ago was not to have teeth filled, and that is what people expected; they would have extractions. But I will bet my bottom dollar that most of the people sitting in this room have almost all of their own teeth, and we are a good example of the Ontario population. It is only our older people who do not have many of their own teeth.

Mr Johnson: Lots of silver.

Dr Hamilton: Lots of silver. Well, silver is fine. There was an article in the paper this morning about the mercury that is the problem.

Mr Beer: Your timing is perfect. I have to confess that I do not have all my teeth.

Mr Owens: Which ones, Charlie?

Mr Beer: That is for you to determine.

I would like to raise a question about the dental hygienists, and the whole question of the future direction of health care, the decentralization in the homes, communities and so on. In a practical way I do not see how, as we move on with long-term care, you could look in the mirror even under public health, and say to yourself "I am still really directing the work of these dental hygienists" in any way that had legal carriage. Is there not some way that we can define the role of dental hygienists so that those sorts of services would go forward? Or do you just fundamentally believe that simply by way of training they are not able to do that, because it seems we are going to run into a major problem there?

Dr Hamilton: I think if you do that you may have to separate dental hygienists employed in private general practice from those who are employed on their own. I do not think you want to do that. You likely would have to have separate training programs.

I disagree a little bit with the suggestion that hygienists who are out in the field in long-term care, let's say, are not appropriately directed, because they have, in many cases, more strict guidelines than in a dental office. There are policy and procedure manuals; they know exactly what they are; they say, "This is what you must do, must do, must do." They know that if there is anything that is outside those boundaries they will consult me by phone or wherever I am -- they can always get hold of me -- and ask. I think the intent of the legislation was to make sure that we were able to use auxiliaries above and beyond just dental offices.

Mr Beer: And you do not think that could be handled through the College of Dental Hygienists of Ontario, where they themselves, as responsible professionals, would recognize that "Beyond this point our practice cannot go and we would have to refer back"?

Dr Hamilton: Sure. If that was in the legislation, it could be handled. My concern is the part about the independent practice. If that goes through, then you could have entrepreneurial dental hygienists establishing practices in, let's say, a collective living centre on their own with no guidance at all. That is a serious problem, in my view.

The Chair: We very much appreciate your presentation. It is nice to see you again.

Dr Hamilton: Best of luck.



The Chair: Sudbury Nurses for Life. You have 20 minutes.

Ms Petrucka: My name is Diane Petrucka. I am also a Sudbury native and like all northern Ontario natives, I will get to the point.

This presentation today is by our group, Nurses for Life, for the purpose of proposing a general regulation under Bill 57, or a regulation under the proposed Regulated Health Professions Act, Bill 43.

First of all, some background on Nurses for Life. We are a non-sectarian organization of health professionals dedicated to the defence of human life from conception to natural death. We believe that the destruction of human life is in direct contradiction to the moral and ethical responsibilities of our profession. We believe the definition of nursing demands that nurses utilize the scientific information and skills they have before them to affect life and health. We recognize the value of and support research beneficial to all humanity done with consideration for the dignity, and with full and informed consent, of the individual involved.

With this in mind, Nurses for Life has been involved in fighting not only for the legal protection of their moral obligations within their profession, as we see it, but also for the protection of all those who are defenceless and in need of legal protection. Today before this committee I will attempt to show the need for legal protection for conscientious objectors within this proposed act, Bill 43, as well as its related act, Bill 57, the Nursing Act.

As this act stands now, the implications, I believe, to nursing in general will provide a very tenuous position at best in the decision-making process as we understand it. Under clause 5(1)(c) of Bill 43, it appears to us that the minister will have the ultimate power to amend, revoke or constitute whatever regulation the minister sees fit under the new bill. Our general concern is that once regulations are set down, we -- the nursing profession -- will be at the whim and will of a very small concentrated power, as shown to us in sections 11, 12 and 13 of Schedule 2, Bill 43.

It is noble to want to attain the goal of obtainable health services for all, a right that should be given to each individual client by qualified professionals who are controlled by a specific procedural code germane to their profession. However, it is unrealistic to expect that the minister, who would essentially hold regulating powers, should ultimately have final control over each council's procedural codes and guidelines by having the power to deregulate without need of approval or advisement from whichever council would be involved.

This, in our opinion, would constitute totalitarian control of the councils and professionals working within these councils. Essentially, the decisions and the very will of each individual will be controlled by a very few select, non-medical government officials.

The basic substance of the act may have been written to initiate and control each profession with a council where none existed before. However, it seems that there is no faith instilled in these councils' abilities and activities, such as already exist in medicine and nursing, when these particular bodies will have essentially no power to govern their own without final approval from the minister, and the lay advisory board.

The reasons I put this critique before you is that I believe history will be repeating itself. I am referring specifically to the presentations made on another bill by Nurses for Life in its struggle to obtain a conscience clause designed specifically for health care professionals within this country. It was introduced at the time as an amendment to the proposed Bill C-43. It was turned down in the end, as were all amendments; a waste of time and money, I believe, since the political will seemed not to want to recognize inherent human rights of professionals at that time, nor those of the unborn.

Also, under the previous provincial Liberal government, a similar proposal was made first by me through Shelley Martel, our MPP for Sudbury East, to obtain protection for nurses involved in and seeking protection from assistance with abortions within our hospital. At the time, the answer was that the hospital management should take, and supposedly was taking, care of the problem, which of course in the end it did not. If one had a sympathetic management team that understood the need for respect of an individual's personal or religious and moral rights, then the problem would be solved. But then, again, that is no answer. It does not provide what would be best controlled by law, a uniform law. Here again, what exists is control of a person's basic human rights by a few in management positions.

Subsequently I was also able to present the question to our own Ontario Nurses' Association before our recent contract: Should nurses have the right to refuse to assist with abortions without recrimination from management? Of the people who answered the questionnaire, 75%, which came to approximately 11,000 of our members, said yes, nurses should have the right to refuse. It was astonishing to know that even though money and pension issues were addressed as the forefront issues, this question did get such a positive response. That is why we are in desperate need now of legal protection.

We seem to have to fight for what is already ours, supposedly, in our democratic system. Yet it seems democracy wears many faces these days. Is it democratic that the political will of those in power should achieve, through what I believe is domination, aggression or instigation of reprisal, those laws which would deny personal choice among those individuals who happen to be health care professionals? This certainly does not make any logical sense.

It is as though we, as women in a profession consisting mainly of women, are not deemed worthy enough to have the choice, the right to say no. It is important and necessary for those people who do have the power to initiate legislation and/or regulations to believe that we as nurses have as much right to our beliefs as, for example, the Sikhs who created so much national turmoil over their turbans. I would think we would be worthy of as much interest.

The words we are trying to convey, basically, are that freedom of personhood and democratic rights should know no boundaries in this country and in this province. Prejudice, bias and perhaps fear of the unknown are the only blocks which prevent us from attaining what is already inherent to all of us in the Charter of Rights, but seems to be excluded from us because of our profession. This to me is discrimination and our proposal should provide adequate protection within the bill for all who require it in the health profession.

Such protection should involve two elements, and this is what I believe should be brought into regulation. The first is the protection of conscience. No person should be compelled directly or by threat of penalty to be an unwilling participant in an abortion procedure or any procedure which would deliberately end the life of another human being.

The second is the right to protection against discrimination. No person should be impeded in his or her career path by an exercise of personal conscience. Both of these elements are necessary, I believe, to ensure adequate protection for nurses.

We offer four reasons in support of special protective legislation. The first is consistent with the spirit of the Canadian Charter of Rights, as I mentioned, specifically in sections 2 and 15 of the charter which guarantee that everyone has the following fundamental freedoms: freedom of conscience and religion and freedom of thought, belief and opinion.

Also, every individual is equal before and under the law and has that right to the equal protection and equal benefit of the law without discrimination and, in particular, without discrimination based on race, national or ethnic origin, colour, religion, sex, age, mental or physical disability.

These provisions might be thought to offer nurses some protection. Unfortunately, it is not clear whether they apply to hospitals, especially in the area of employment relations. Even if hospital action is subject to review under the Charter of Rights, there are no decided cases that clearly establish protection for conscientious objectors nor, to the best of my knowledge, are there any cases pending in the courts on this issue at this time. The absence of expressed protection creates uncertainty which discourages nurses from asserting their rights. That is why legislation is needed to clarify the matter.

Protection for nurses is also consistent with the spirit under the provincial Human Rights Code under sections 10 and 14, which provide that, "Every person has a right to equal treatment with respect to employment without discrimination because of creed," and following as well, "Every person who is an employee has a right to freedom from harassment in the workplace by the employer or agent of the employer or by another employee because of...creed." It goes on to mention and to clarify also under section 10. Because of time I will try to move on to page 6.

However, a significant difficulty with the provisions listed before you is that the provisions leave too much to implication and inference. The right of conscientious objection and the protection from discrimination are not expressed and can only be achieved by a nurse after protracted legal proceedings. Nurses need better and more express protection and their employers need certainty.

Third, protection for health care professionals is consistent with the protection given to them in other free and democratic societies. Providing conscientiously objecting nurses with some form of legal protection would not be a uniquely Canadian development. Numerous other free and democratic societies have provided just such protection.

There is no legitimate reason for denying this protection to Canadian nurses and other health care workers when legislation for complete protection has long been in existence in Britain, New Zealand, Italy, France and 44 of the United States of America, most significantly in Illinois, Washington and Texas.

First of all, the one in the United Kingdom has been in effect for 21 years. The one I would like you to pay most attention to, which is most specific and, I believe, relevant for nurses, and which I would like to have initiated in this legislation is the one from the United States of America on page 8.

To date, 44 American states have enacted legislation granting special protection to conscientiously objecting nurses and other health care workers. In general, these provisions allow nurses who express an objection to assisting in abortions on religious and moral grounds to be exempted from doing so. They explicitly protect nurses who voice such objections from subsequent discrimination. Some also expressly prohibit discrimination at the hiring stage.


For example, we believe the best one is the Texas legislation which provides under section 1, that "A physician, nurse, staff member, or employee of a hospital or other health care facility who objects to performing or participating, directly or indirectly, in an abortion procedure may not be required to perform or participate, directly or indirectly, in an abortion procedure."

It goes on to state what these health care professionals may do if they find their rights are being violated. It is very well expressed in this Texas legislation.

Such protection, it is suggested, should also be given to Canadian nurses. Doing so would be consistent not only with provisions enacted in other western jurisdictions but also with current Canadian moral standards as expressed in the ethical codes of various Canadian professional organizations. Protection of nurses is consistent with the ethical codes of professional organizations in the medical field such as the Canadian Nurses' Association. The code of ethics adopted by the Canadian Nurses' Association provides that a nurse is not ethically obliged to provide requested care when compliance would involve a violation of his or her moral beliefs. When that request falls within recognized forms of health care, the client should be referred to a more appropriate health care practitioner. Nurses who have or are likely to encounter such situations are morally obligated to seek to arrange conditions of employment so that the care of the client is not jeopardized.

The code recognizes an ethical sphere within which nurses are free to act in accordance with their personal beliefs. Nurses are not obliged to remove themselves entirely from an area in which ethical concerns are likely to arise. Also, I have listed the Registered Nurses' Association of Ontario that has adopted a policy statement in 1988 on the right to refuse to participate in care. Part of that policy says:

"The primary focus in such discussions must be on the good of the patient and the obligations of the individual nurse and the health care agency to provide care.

"Despite that, whenever possible, consideration should be given to the right of the health care provider to request relief or transfer from active involvement in caring for patients undergoing a procedure which would violate the provider's religious beliefs."

Specifically, note that the transfer is simply a transfer from active involvement in caring for the patient undergoing that particular procedure. However, it leaves us to wonder why, if such codes are indeed in place, why there has been no support in practice for the rights of conscientious objectors in this province. When is it all to be enforced and put to rights? Again, it is imperative that legal protection be provided through legislation.

If one might take a true example of an existing and effective code, it is that which exists within the Canadian Medical Association code of ethics for physicians. This one, I believe, explicitly provides physicians with the protection we as nurses are seeking. Paragraph 12 guarantees the physician an absolute right, except in an emergency, to refuse to accept a patient. No reasons are needed for such a refusal. It follows therefore that a refusal on moral grounds would be perfectly acceptable. In addition, paragraph 16 emphasizes that even when a physician has accepted a patient, he is not obliged to recommend a form of therapy if he is prevented from doing so by his conscience. The only duty in such a case is for the physician to tell the patient of this fact.

The Canadian Medical Association has explicitly considered the abortion issue. In a 1985 policy statement on abortion, it unequivocally stated that: "The association . . . supports the position that no hospital, physician or other health care worker should be compelled to participate in the provision of abortion services if it is contrary to their beliefs or wishes." This statement also includes nurses.

The Canadian Medical Association again considered the abortion issue in its 1988 policy summary. This 1988 policy statement on induced abortion states:

"A physician should not be compelled to participate in the termination of a pregnancy...

"A physician whose moral or religious beliefs prevent him or her from recommending or performing an abortion should inform the patient of such so that she may consult another physician.

"No discrimination should be directed against doctors who do not perform or assist at induced abortions. Respect for the right of personal decision in this area must be stressed, particularly for doctors training in obstetrics and gynaecology, and anaesthesia."

We believe these concerns apply equally to nurses.

Finally, the concern has been raised regarding the functioning of hospitals. It may be argued that the protection sought here will impair the functioning of hospitals. We do not believe this concern can be justified when it is analysed. It can be possible for employees to arrange work schedules of nurses so there is someone available on any particular shift who has no conscientious objection to abortion procedures.

Further, the administrative problems should be seen in context. In whatever area abortion procedures are performed, be it obstetric, gynaecology, operating room, day care, surgical wards, these procedures constitute a minority percentage of the cases done in these wards. It is therefore not reasonable to exclude these nurses from their trained specialty areas because they may conscientiously object to abortion procedures or to any other procedures that would deliberately end the life of any human being.

We therefore believe legislation should be introduced in the form of a regulation instituted by the minister through the auspices of the proposed Bill 43. The legislation could adopt the format used in other jurisdictions mentioned previously, thus enacting a basic prohibition against both compulsion of and discrimination against health care workers involved directly or indirectly in abortion. Should the proposal statutes be violated, the legislation should also include recommended steps to protect these individuals unequivocally. Nurses for Life strongly recommends legislation similar to that adopted by the state Legislature of Texas.

Our concern as an organization is to ensure legal protection for all as soon as possible. This has been reiterated both federally and provincially. Why is there no law yet? There is no reason. The ideology of choice must be extended to conscientious objectors here in Ontario, Canada, and not only to a select group of Canadians. It is time, ladies and gentlemen, to accord us the right of conscience and protection against discrimination. These rights are ours and we should not have to beg for them any more.

Respectfully, I thank you very much for hearing me.

Mr J. Wilson: I was just wondering, you mention Bill C-43 and that you have made representations to the federal government which is probably where the remedy you seek should be on the abortion issue. Have you made representations at the provincial level and if so, what is your response?

Ms Petrucka: This is the first presentation I have made at the provincial level, representing the group before a committee. If I may make a comment on what you are saying about the national level, they said, "Well, no, it belongs to the provincial level." So, as I say, the buck has been passed on and I figure the buck has been passed on long enough. That is why we are going to be seeking through provincial legislation that each province enact, through its own provincial Regulated Health Professions Act, regulations that would protect conscientious objectors in each of their own provinces.

Mr J. Wilson: Because the federal government felt it was a health care service.

Ms Petrucka: That is right.

Mr J. Wilson: Are there any other examples of procedures or actions that nurses may object to on religious grounds?

Ms Petrucka: They would probably have to introduce that themselves. What I am referring to specifically is abortion. We also include euthanasia procedures that we know are not recognized legally. I know for a fact that it is happening in hospitals today but it is not recognized legal procedure, so if that were to be recognized at some time in the future, we believe on moral grounds that we should have legal protection to be free from assisting in that as well.

Mr Beer: I was going to raise the issue of euthanasia as something which, while not legal to date, clearly if we just look in the recent news magazines, is an issue that we are ethically going to have to deal with. At the present time are you aware of nurses who have refused to participate in an abortion procedure? Has anyone been disciplined for that? The reason I raise that is whether you simply want to have protection in principle. Is it an immediate problem?

Ms Petrucka: Yes, it is an immediate problem. That is why we came into existence. We are seeking it not because we have just planned it now. It arose because of the problem that existed in various hospitals, not only in Ontario but across Canada.

The Chair: Thank you very much. We appreciate your coming before the committee today. If there is additional material that you think would be helpful to the committee, you can submit it in writing.


The Chair: Rick Geroux. Welcome. You have 10 minutes for your presentation.


Mr Geroux: My name is Rick Geroux. I am a 38-year-old local businessman and father of four. I have been involved in sports for most of my adult life and my interests have primarily centred around competitive power-lifting and body-building. I have competed at Ontario and Canadian levels in power-lifting and I have achieved a provincial-level judging certificate as well as coaching a number of amateur, provincial and Canadian-level body-builders.

My reasons for stating these facts are not for pride's sake but to help you as a group to understand my credibility in the sports injury field. Injuries are an unavoidable fact of life, but the diagnosis, treatment and prognosis are of great concern to any athlete at any level. My first involvement with chiropractic may have been spinal-related, but it was not long before I realized that due to the understanding of the nervous, skeletal and muscular systems, a chiropractor could be of great service to athletes in a wide variety of ways.

On one specific occasion, I damaged the tendon of my right extensor carpi ulnaris on my forearm. The medical doctor I visited diagnosed a tear of the same but gave no treatment other than long-term rest and possible surgery. Because of my respect for Dr Dean Love, a local chiropractor, I consulted him regarding the injury and with the use of ultrasound, massage and ice to reduce inflammation and scar tissue, my arm was fine and I returned to training not only with a functional limb but an understanding of how to reduce the possibility of injury. On numerous occasions I have encouraged not only those under my training but my peers to seek the care, compassion and consultation of Dr Love with regard to wrists, knees, shoulders, ankles and any other injury related to muscle, tendon or joint.

It is my understanding that there is proposed legislation that may not provide for detailed diagnosis and management of injuries such as these by Dr Love or his colleagues. Due to the expert care that I have experience, I would consider this to be a grave mistake.

Mr Beer: It will perhaps come as no surprise to learn that a number of people have raised this particular issue. I guess the answer at the moment has been that chiropractors can treat those sorts of injuries, but the question is around the diagnosis. I simply wanted to underline that we realize this is an issue we have to come to grips with and we have had a number of examples such as the one you have given here, and we will be considering that.

Mr Geroux: The basic point that I think has to be stressed is the right to diagnosis. I listened to the lady before us. We seem to be losing so many rights. And I think we have to be careful. If I have an injury that I know can be solved easily and inexpensively through our medical system but I have to walk a different road, I think we as taxpayers not only suffer monetarily but we will suffer physically.

Mr Beer: Again, what we have to wrestle with here is the balance between the protection of the public and the consumers' right to make a free choice about the service, but it is also important that you be protected. I guess that is what we have to ensure.

The Chair: As I have told other presenters, if you think of anything that might be helpful for the committee members, please submit it in letter form or written brief to our clerk during the course of our deliberations.


The Chair: Pat Jolin. Welcome. You have 10 minutes.

Mr Jolin: I am glad to see once again in Sault Ste Marie we have some participation from the government side, I hope our side, to the goods and bads of this thing.

My name is Pat Jolin. I live at 27 Hawthorne Avenue here in Sault Ste Marie. As some of the honourable members are well aware, I have had occasion to speak before on different priorities the government had towards injured people.

I was a licensed class-A mechanic at the time of my injury, in the heavy equipment field. I was injured in September 1977 in the company truck. The road was washed out and I was taken with it and it caused many of my injuries. I pulled myself up to try to prevent injury and I fractured and injured my shoulder and neck. It caused a lot of ongoing problems.

My subsequent experiences with the workers' compensation system were so frustrating that three years ago I helped to establish, and am president of, the Injured Workers Advocates of Sault Ste Marie, which is a very strong organization. We are nearly 500 strong. Our organization is currently working through the Sault and Algoma as well, which takes in quite a territory.

When I got my shoulder injury in 1977, I first contacted the company physician through phone calls; I also saw one. I was told there was nothing wrong, just keep an eye on it and let it go. His diagnosis was that I just bruised it and to keep an eye on it. So I continued to have a lot of pain and problems but I kept on working and I remained working for approximately two to three months. I blacked out one day coming down the Montreal River hill. It is on 17 north, where the Edmund Fitzgerald went down. It is about a 5,000-foot drop there. My truck was halfway down the drop. So when I did come to, I was very upset and disturbed. I phoned my immediate supervisor and went into the hospital to be checked out.

The orthopaedic surgeon who saw me at that time, after numerous X-rays and about five doctors later, was Dr Fyfe and he explained what had happened. He said I had fractures in the clavicle and the AC joint and this was affecting the nerve supply to my head and it was the cause of blackouts. I had surgery to remove part of the clavicle at this time. The operation was not successful in reducing the constant pain and restricted movement of my shoulder.

Dr Fyfe then explained that the only thing further he could do was major surgery involving breaking my chest bone, and removing part of heart and my insides to operate on the damaged part of my back from the inside instead of outside. At that time, he referred me to Dr Rod Myers, who is a chiropractor here in Sault Ste Marie and who he said had a very good understanding of shoulder and neck problems and might be able to help me and save the need for further surgery.

When I had my first visit to Dr Myers I was immediately impressed by the detailed examination and understanding he had of my shoulder problems as well as my neck problems and everything else that was involved, as a whole. I brought in the hospital X-rays with me, which he studied and explained to me very explicitly, right down to detail, exactly what the problems were. After the various tests he made through the examination he explained the mechanical problems of the joints and how the various muscles and nerves and even my neck were part of the problem. He then attempted to start the motivation of chiropractic treatment on me.

He treated me with traction, manipulation of my neck and shoulder, pressure points and muscle work all around my shoulder, and electrotherapy. He has kept me functioning well ever since and I have been most grateful to have avoided surgery, because without the treatments, I cannot even walk, I cannot talk properly and lately I cannot even write. From the outset, he explained he could not cure my shoulder. There was no way he could, because of the effects of the bone injury and the surgery. His goal has been to keep me functioning and he has done such a fine job that I have recommended him to almost everybody I have met. He was recommended to me by Dr Fyfe and also my family physician. I have had nothing but compliments from them on what he has done up till this day.


I am told that the suggested new law would prohibit chiropractors from diagnosing these problems in my shoulder and other non-spinal joints, as well as other people who have the same problem as myself, and it would provide that only a medical doctor could make the decision to make a complete and thorough diagnosis. This is not my experience at all, as I have just explained briefly. I do not believe in it for the simple reason that I have had some problems with doctors who do not believe in chiropractors. I will get into that a little bit later if we have time.

From the many claims I have handled with the organization that I lead, Injured Workers Advocates of Sault Ste Marie, I know that this change in the law would create a lot of extra hassles with Workers' Compensation Board claims mainly. A number of workers have been told by WCB staff that chiropractors should not be diagnosing or treating extremity joint injuries. Given my excellent experience with chiropractic, I have sorted out a lot of these problems and encouraged these workers to see chiropractors with good results. At that time, if the chiropractors cannot help them, they will advise them to go to their MD or their family physician or whoever it is.

If the law is changed to prohibit chiropractors from diagnosing non-spinal joints, the WCB consultants and staff, who are some of the doctors I just explained about who are giving us problems by verbal abuse, by being biased -- these workers will lose their rights to choose chiropractic care. I even have some examples which I will get into very briefly afterwards. I cannot imagine why the government would want to do this when chiropractors usually have a more detailed understanding of medical joint injuries and produce quicker and better results. They can also save surgery and a lot of money, as in my case.

Further to this, what I have are a couple of examples of a situation. I believe you have a copy of --

The Chair: Yes, we received your written presentation.

Mr Jolin: Okay, and I believe you also received a copy of a documented proof which was in southern Ontario. I would like to bring that up, as it has also happened here in Sault Ste Marie, and in my dialogue book of representations -- I average anywhere from three to sometimes five a week, sometimes many more, verbally or with the Workers' Compensation Board, as well as with the family physicians. What happens is the extremity joint problem is very ongoing. I myself have seen seven different doctors and they have said there is no way I could be helped; I have to suffer pain for the rest of my life. In turn, I went to a chiropractor, as many of my clients did, and we were relieved of our pain through temporarily solving problems with chiropractor treatments.

I had a special occurrence here just within the past two-week period of going to a special clinic in southern Ontario, which has not been funded by your government or by the WCB. They say they do not warrant it because they do not recognize some of these doctors.

The chiropractors keep me walking, talking and writing, and the doctors say there is nothing more they can do other than just give me pain pills. I am sick and tired of pills, and I am not the only one. I have nearly 500 clients. I would not say all of them are in the same boat, but a number of them are. At my meeting, which was just this past week right here, I asked for a show of hands, and one third of the whole audience put up their hands. They cannot survive without chiropractic treatment, and the chiropractor was very observant to inform them that their problem is in their joints and in muscle-relaxing. All doctors do is give you pills and send you home to bed; you have to stay off work for a week, whereas if you take ongoing treatment, you do and you can motivate enough to keep a job, and that is our main goal, to get back to work, to be in the workforce.

Again, there are another couple of small items which are not that relevant, but I do have a couple of distinct cases that I could bring up if time permits afterwards.

The Chair: You have less than a minute.

Mr Jolin: Yes, okay. It is the rights of the workers' choice, which I believe we should have, between doctors and chiropractors. As far as I am concerned, I have had nothing but good luck with chiropractors. Doctors, there are some of them I could take them outside and run over them, because they have done more harm for me than good. I am not the only one, and I am not choosing sides, because there are beautiful doctors out there. As you know, they can do the operations and what not.

But I do have three examples of this in my care. Chiropractors can diagnose strength problems, I believe, better than doctors. Doctors do not know your life history. A chiropractor will sit down with you, listen to you and go through the whole system with you and feel it and check it out. Before he will even do anything which might cause harm or do good, he will let you know. I believe that should be kept on and the legal foundation or law which is going on here right now should not change. If anything, it should change, in my opinion, in the condition of the chiropractor.

The Chair: Thank you very much for an excellent and thoughtful presentation. We appreciate your coming before the committee today and sharing your views with us.

Mr Owens: On a point of clarification, Madam Chair: As we are having the different ministries come and speak with us during the week of the 16th, I am wondering if we could ask the parliamentary assistant and the ministry staff to get in touch with this presenter to determine the numbers of people who have been denied WCB claims because of their association with a chiropractor.

The Chair: Mr Owens, for your information, the request has already been made for the WCB itself to provide that information to the committee during those weeks, but your request is duly noted and I would say to the presenter that if you have any data, statistics or information that you think would be helpful, following Mr Owens's request, we would appreciate it if you would send it into our clerk in written form so that we may consider it during our deliberations.

Mr Jolin: I have many cases that are similar to mine and it should be noted, I do believe, by the government, because they stood behind me when I was in the Legislature many times, as you well know, representing the injured people across Ontario and across Canada, if need be, and this is still the ongoing thing.



The Chair: J. D. Wilkinson, please come forward. You have 10 minutes for your presentation.

Mr Wilkinson: In introduction, as you may have observed quite quickly, I do have a visual disability. I will not be able to respond visually to any of your queries, so I appreciate the verbal response. Thank you.

My name is J. Denny Wilkinson. I have several positions, as you will note on the brief submitted to you. I am a registered massage therapist, I am a nutrition and health consultant, I have a doctorate in naturopathic medicine, I am an associate member of the Canadian College of Natural Healing, a certified practitioner of the European Community and a member of the International Academy of Natural Health Sciences. I have been director of the Natural Health Clinic in Sault Ste Marie for some 10 years.

I am not specifically going to read the brief, I am just going to discuss a number of points within the brief rather than attempting to read it. Primarily, the objectives are, first of all, to complement, and second, to criticize the current legislative proposal and make several recommendations for improvement of the concept and recommend some changes in interpretation of health care, that is, a look at the two models of health care, the medical model and the natural health model; and last, to recommend some development for consumer education and, of course, a look at professional education.

First of all, the compliments and critiques: Certainly high commendations are in order to all who have come to this point over the years to develop this long overdue legislative package. The inclusion of the choice factor is indeed a most important aspect. The move also to self-regulate and bring in the ecologies of the various professions is certainly extremely well accepted.

The question arises, however, about the controlled acts. The diagnostic clause has received a tremendous amount of attention, and rightly so. However, looking at the approach to colleges, and assuming that their mandate is to administrate and support their members in their work, would they not in essence develop that area, what we call controlled acts? Would they not in fact be better left in the hands of the colleges? They know their members and they know their training. They know what is required. If in fact the freedom of choice is going to be there, is the consumer not responsible for choosing the right practitioner, without a great deal of legislative-type protection? Any act is a high risk if it is performed by an untrained person.

I understand from the materials I have had access to that much of the argument is turf battles. Each individual practitioner or group of practitioners just wish to maintain a high standard for themselves, and really without much due respect. Some of the material I was reading was about the ophthalmologists not being too happy with the optometrists, the obstetrician is not happy with the midwives, the dentist is not happy with denturists and dental hygienists, etc, and it appears to me to be simply turf battles. I would suspect there are enough consumers out there who could make a choice, and it would certainly keep everybody busy. I do not think there is any lack of business, and I get the distinct feeling that much of this controlling is for turf protection, rather than for consumer protection.

There are in essence only two models of health care practice. One is the medical model and two is the natural model. It would be well and quite worthy, I would think, as a suggestion, to look at the Quebec plan at the present time, and maybe some adaptations of the Quebec plan and maybe the acceptance of the naturopathic practitioners from Quebec and their standards. A good look at that would be quite valuable.

Education: If in fact the consumer is going to make a choice in his health care, he really needs to make an informed choice. Therefore, some education is going to be necessary. A recommendation might be that the Ministry of Health -- not the professionals, although in consultation with professionals -- define an educational format, an educational program for citizens so that they are aware of choices. It is very difficult to say, "You have a choice," if the average consumer is not really aware of what those choices mean.

A second major area might be, through the Ministry of Education, a development through the school curriculums. We have seen a number of times that teachers have been very biased towards various other professions, other than the medical profession. Professional education, of course, is also very important, and we do need to do some development in that area.

The natural health model appears to be one of the most important areas of development, and there are some very well-established educational facilities now available in naturopathic medicine, in homeopathy, in herbalism, etc. All these can be defined. The Canadian College of Natural Healing, the Ontario College of Naturopathic Medicine and, of course, many others are truly available, whether they are on-shore schools, that is, Canadian schools or in fact international schools, as we are finding out in our international academy, with some excellent programs.

Naturopathic doctors and medical doctors both have medical branches, but I know it has been a real difficulty in defining or trying to find an establishment of naturopaths. There is only one difference between a naturopathy doctor, I respectfully submit, and a medical doctor, and that is that the naturopathy doctor does not use drugs or surgery. That is specifically part of the medical model. We are not by any means saying that one is better than the other and we feel definitively a program of co-operation is needed. Some people definitively prefer to have a medical doctor, a medical practitioner. Some people prefer to have a naturopathic practitioner. When I say naturopathic, I mean anything from the naturopathic doctor to the chiropractic, to the osteopathic, to the herbalist, homeopathy, etc. We believe in the work that we are doing through our international levels, that the consumer has to have that choice.

The naturopathic doctors and the medical doctors of whatever branch should be accepted as equals with due respect for each other. We find too many of these turf battles. The United Nations has actually declared so, that we should be in that vein of thinking, and the Canadian College of Natural Healing up in Ottawa is Canada central for the European Community and the international community.

We are really at the dawn of a brand new understanding in health care and we are committed to assisting in the development of this kind of process where the consumer will have a full range of choices. It is hoped that these turf battles will disappear, because it is the consumer who gets locked in the middle of the turf battles. Many good practitioners are in Ontario right now in naturopathy or from the Ontario College of Naturopathic Medicine and from international schools. We have many good chiropractors, osteopaths, etc, and this program of development needs to come through.

In economic terms, finally, I would suggest that if the consumer has that freedom of choosing, is definitively choosing, much of the economic value would be very well noticed and acceptable. If a consumer prefers to have a naturopathic physician, the insurance plans would do well to respect his or her choice, and to pay either model, whichever the consumer chooses.

We are committed to developing this area of co-operation in our province of Ontario, to develop a system that we can all be proud of. Our goal is for all of us to work together, to support each other, to consult with each other, and not deal with the turf battles and who can do this and who can do that. The professionals themselves, through their colleges, know very well what they can do.

The Chair: Thank you very much for a very thoughtful presentation.



The Chair: I call the Algoma Physical Rehabilitation Clinic. You have 20 minutes for your presentation.

Mr Salituri: Thank you. I am your last speaker. I am sure when you were all coming up to Sault Ste Marie, our good MPP Tony Martin told you how cold it can be in the Sault at the end of August. In fact, it has snowed --

The Chair: That is the last of his presentation.

Mr Salituri: I am sorry, Tony. There goes my job as his campaign manager for the next election.

It is a pleasure to have you up here in Sault Ste Marie. Usually, these processes for some reason seem to bypass us, so welcome to the Sault. Hopefully, you had some time to enjoy our area. My name is John Salituri. I am a physical therapist, and this afternoon I want to speak to you on behalf of the physical therapists who practise here in Sault Ste Marie. In fact, I am a physical therapist who practises in a private practice here, and that is what you see in your agenda, the Algoma Physical Rehabilitation Clinic. There are three other physiotherapists who practise with me there.

My purpose this afternoon is to discuss the Physiotherapy Act which is part of the regulated act. Specifically, I will convey to you our thoughts and concerns on how the present content of the act will affect physical therapists and our patients on a daily basis. The committee has already heard a submission from our provincial professional body, the Ontario Physiotherapy Association. We firmly support that submission and now wish to add our grass-roots perspective on the issues raised by the OPA.

We are very pleased that this process has now led to a commendable legislative act. We especially support the objectives of the act, specifically the protection of the public from unqualified health providers, and confirming the right of individuals to choose and have access to the health care they deserve, including physical therapy.

This act can be improved by addressing the following three issues: First, the protection of both our titles, that is, physiotherapist/physiotherapy and physical therapist/physical therapy; second, communication to our patients of our professional opinion regarding their complaints, that is, diagnosis; and third, performing procedures below the dermis.

With respect to protection of title, I am a graduate of the faculty of medicine, University of Toronto, and my degree is in physical therapy. I will ask that you turn to appendix 1. There are several appendices I would like you to put your attention to as I go through my presentation. You will see that this is a copy of my degree, and you will see that it states quite clearly that I have a bachelor of science in physical therapy.

As outlined clearly in the OPA submission, the terms "physiotherapy" and "physical therapy" are interchangeable. In fact, the term "physical therapy" is most commonly used in the world, as well as by recognized degree-granting institutions such as the University of Toronto. As an adjunct here, I also have a licence to practise in the United States and my licence in the state of Michigan states that I have a licence to practise physical therapy.

It is understood that physiotherapy and physical therapy can and should only be performed by physiotherapists or physical therapists. In co-operation with provincial medical doctors, the procedure of physiotherapy/physical therapy has been removed from the OHIP schedule of procedures that they may bill for. This is in recognition of our exclusive right to practise physiotherapy and physical therapy.

Please refer to appendix 2 for an example of how the term "physical therapy" has been used inappropriately. This is a commercial circular that came to my attention. If you will draw your attention to the bottom quarter of the page, you will see I have highlighted for you one of the points, "Four hydro-therapy jets provide relaxation and physical therapy." I am sure we all agree that inanimate objects such as a hot tub cannot perform physical therapy, as much as a paintbrush alone cannot perform painting. The obvious point here is that only qualified health professionals can deliver part or parts of their scope of practice and, therefore, title and scope of practice must be fully delineated in this act.

In order to ensure that the objectives of the act are met, that the public not be confused about what acts or health care professionals are competent, both the titles of physiotherapy/physiotherapist and physical therapy/physical therapist must be protected by this legislation. This change then will reflect reality.

The second point that we would like to bring to your attention is diagnosis. There is an unfortunate omission in the Physiotherapy Act that does not recognize the fact that physical therapists question, examine, deliberate and form a conclusion with every single patient that we face. We must then, by ethical standards, properly document this process and communicate our conclusion to our patients and act on it appropriately. This process is commonly termed "diagnosis." It is not the exclusive right of any health professional group to engage in this process. In fact, diagnosis is a part of good clinical practice and patients' fundamental right.

Physical therapists as primary care clinicians must continue to diagnose within our scope of practice. We do not infringe on diagnoses that are the realm of other health care providers, for example, the diagnosis of diabetes.

In our daily practice there are examples of our skill to diagnose within our scope. It is common knowledge that the majority of our patients are referred to us by physicians. Most of these referrals, however, do not provide diagnoses and we, therefore, must diagnose before deciding how to treat the patient, or if our intervention is appropriate at all. As well, it is common for physicians to request our physical therapy diagnosis so that a clearer clinical conclusion can be achieved.

If you follow me through the next few appendices, I will give you an example of what happens daily in physical therapy practices across the province.

Appendix 3 is from a circular that was created by the board of directors of physiotherapy. It was actually presented to the committee previous to this as this process was going on. I draw your attention to the right-hand side of the page, the table entitled, "Survey of Diagnoses Provided by Physicians on Referral Forms for Physiotherapy." Two clinics were involved in this survey, clinics 1 and 2, and I have highlighted the results of those. You can see that in clinic 1, specific diagnosis was only provided in 10.7% of the referrals, and in the majority of the other referrals, it was nondescript and it was perhaps just a description of the patient's complaints. Similarly, in clinic 2. The point here then is that referring physicians usually do not provide a specific referral. Therefore, it is up to us to make sure that we go through that process before treating.

Appendix 4. This is an example of referrals with no specific diagnosis, requiring physical therapists to diagnose before treating. This is the referral form we use in our office. Under the heading of "diagnosis" I have highlighted the word "back," and this is what the physician has written here, simply "back." This is what I am faced with when I see patients. So obviously I must go through the process of diagnosing before deciding what to do with this patient.

Similarly, in appendix 5, the diagnosis is low back pain. That is really not a diagnosis, that is a description. He queries here that it is discogenic, but again, we must go through the process of deciding what is wrong with this patient before we can obviously treat.

Appendix 6. Here the referring physicians are not sure of the diagnosis and our thoughts are requested. We, therefore, must provide a physical therapy diagnosis. I have circled and highlighted for you under "diagnosis," "NYD." That stands for "not yet diagnosed." I will read the whole line for you. It says, "Right flank pain not yet diagnosed, associated with back pain." Under "objectives" the last two lines read: "I have not yet X-rayed his back. If he doesn't improve then I will X-ray." Basically, this physician is telling us: "Have a look at this fellow. See what you think. Do what you can. If you can't make him better, give me a holler. Let me know what you think and I will X-ray it or we'll investigate it." That is normal daily practice, and there is nothing wrong with that.

Appendix 7. Similarly, the physician's diagnosis, he writes: "Right leg pain. Please assess and call me to discuss." He queries here "Psoas plus or minus SI." Again, we must diagnose this patient, decide what we think the problem is, treat it and let the physician know, and together we come to a treatment plan that is appropriate.

Appendices 8 and 9. Here the referring physicians request our opinion regarding appropriate treatment for the conditions. We therefore must confirm the diagnosis before deciding if we can offer treatment. It must be made clear that diagnosis and treatment are an integral part of the same process of offering good health care to our patients.

Appendix 8. Peter is the name of one of the physiotherapists who practises with me, and the second line of the referral here is a query, "Is this beyond orthotic help?" So when Mr Kotyk looks at this patient, he has to decide whether he thinks the diagnosis is such that the treatment of orthotics is appropriate. He must obviously be a diagnostician to make that distinction.


Appendix 9: this is a referral from an orthopaedic surgeon who has highlighted in his very graphic writing, "Can you help?" Obviously, our surgeon has confidence in the fact that we can diagnose, decide what the problem is and -- "Can you do something about it? If not, let me know and we will go from there."

Appendix 10: As well, the legal profession often requests our clinical opinions and diagnosis. Of course, patients consent to this and thereby also request our diagnosis as their right. Appendix 10 is an example of a legal letter that we often get in our office. Of course, accompanying this is the patient's consent, so the patient knows this is coming. Lawyers in their own way will delineate exactly what they want us to address, and you will see in the many points that this particular lawyer asks, he uses the terms "diagnostic procedures," "conclusions" and "prognosis." These are terms that one expects from somebody who is able to diagnose. Of course, if we are to give an opinion, we in fact are then diagnosing.

Appendix 11: In my practice, injured workers with workers' compensation claims make up our largest group. In the required documentation we must provide our diagnosis. Appendix 11 is a form that we must fill out on all of these appropriate patients. I have highlighted for you "WCB diagnostic codes." What that refers to -- if you flip the page over -- is a booklet that has all the diagnoses known to the clinical world, and they are coded. These codes are being used by several other institutions and not just the Workers' Compensation Board. So obviously, here the board is asking us for a diagnosis and asking us to flip through this book, find which one we think is appropriate, and put it in here.

So the Workers' Compensation Board, of course a reputable institution, recognizes that we, as physical therapists, can diagnose. It is evident then that we do diagnose with every patient and it is an integral part of the delivery of appropriate health care, thereby reflecting the objectives of the act.

The procedures below the dermis is our third and last point. There is an omission in this act of procedures below the dermis, which physical therapists perform on a daily basis. The debridement of burn wounds and acupuncture are the most common examples of such procedures. We respectfully request that the act be revised to properly recognize such important procedures as being within our scope of practice.

Recently, with the friendly amendments, I understand that a procedure which we call tracheotomy or suction of the tracheotomy, which is sticking a suction tube down either someone's nose, mouth or trachea to remove mucus. That is something that came out through the friendly amendments. That is now within our scope of practice. Certainly things such as the debridement of burn wounds and acupuncture are not as invasive as something which is now recognized as within our scope.

In summary then, we are generally pleased with the act. We respectfully request that three amendments be made to ensure the act realistically depicts the practice of physical therapy thereby guaranteeing the spirit and the objectives of the act. First, protect the titles physiotherapy, physical therapy. Second, allow physical therapists to continue to communicate to our patients and pertinent others via diagnosis. Third, allow physical therapists to continue to perform procedures below the dermis. The act will then truly embody the safe and effective practice of physical therapy as it occurs daily throughout Ontario.

Thank you very much for your attention. I will be most happy to answer all of your questions.

Mr Owens: I was going to playfully ask you, as a person registered in the States, whether you thought cross-border physio was a problem, but anyway -- my real live question is with respect to your concerns around diagnosis. In reviewing the samples that you provided for us, I am wondering if in fact you are not performing an assessment within your scope, providing information for the physician to draw a conclusion and make a diagnosis rather than yourself making a diagnosis?

Mr Salituri: No, we are in fact making a diagnosis within our scope of practice. This is what the physicians want. This is what they have recognized. The reason they refer them to us is because they recognize we have a specific expertise. They think this patient needs that specific expertise. Who better to decide whether that expertise is appropriate or not than us, the physical therapists? So we do diagnose within our scope of practice. We do that continually and yes, the term "assessment" is perhaps appropriate; but more appropriate we believe is the term "diagnosis." This is what we have been doing and this is what we do today.

Mr Owens: I guess I am just beginning to wonder whether we have been perhaps a little bit loose with our usage of language for a long period of time, and now that we are trying to tighten things up, we find problem areas where accepted language is not necessarily the language of the function that we are performing. Do you have any sense of that?

Mr Salituri: Yes, I agree with you. Diagnosis is within our realm of practice and it should be there. Perhaps it is not being used appropriately by other people, but certainly when it comes physical therapists, we embody that term. Again, diagnosis is a process; you just do not pick out of a hat. You assess, you question, you examine and then all of that together is diagnosis. You started your question with the term "assessment"; that is part of diagnosis. When you assess you have to come to a conclusion, if you are any type of thinking professional. There you have your diagnosis.

Mr Owens: But I think then it is how you put that conclusion into practice and what you do with that conclusion.

Mr Salituri: Exactly.

Mr Owens: Intellectually, we cannot regulate how you think, but --

Mr Hope: We can convince them.

Mr Owens: Maybe the right-wingers on the committee are the thought police.

The Chair: Actually, that did not come from the right wing.

Mr Beer: Which wing?

I would like to understand a little better how you work on a day-to-day basis with the medical profession. Just using the examples that you have provided us with -- and I thank you very much; that was very helpful -- having then received this and then going about trying to determine what it is that ails these individuals, what then is the ongoing relationship that you would have with the medical doctor who had originally referred these people to you? What would happen?

Mr Salituri: The process that follows then is, if appropriate and if necessary, we contact the physician after first examining the patient by phone if necessary and say --

Mr Beer: I am sorry. You might not contact the patient?

Mr Salituri: We might not if the diagnosis is very clear, if the problem is such that it is amenable to our treatment. We will certainly contact him immediately if we recognize that this referral is not appropriate, there is nothing we can do for this patient. We get back to the physician saying: "I think this is going on and if this in fact is what is going on, there is nothing I can do about it. Please act on that."

That does not happen most of the time. Most of the time the referrals are appropriate. We have excellent communication with the physicians. We communicate with them through telephone and we communicate with them certainly through discharge letters of which I do not have an example here. In that discharge letter it is very much like a physician referring to an orthopaedist or a cardiologist. We outline the examination that we made, the history of the patient, the conclusion, the diagnosis that we came to. We outline in detail the treatment and the outcome of that treatment and recommendation as to further treatment if necessary.

Mr Beer: Would you have similar contact with chiropractors at times or is this mainly with doctors?

Mr Salituri: This is mainly with physicians. I do not know about other areas in Ontario, but in the Sault we have some referral of patients back and forth and yes, this does happen. We communicate with each other and that is part of good health care and, you know, the spirit of this act is such that no one body has rights to the total scope of health care or to decide where you should go within the realm of health care.

To do that we, as health professionals, must interact with each other. The previous gentleman talked about turf war. He is correct in his perception, but those walls are rapidly coming down. As we all recognize, we must work together. This is one of the commendable parts of this legislation. Those of us who do not want to do it now will have to if we are to make this thing work.

The Chair: Thank you very much for your presentation. Comments? Mr Martin. I thought you would want the last word.

Mr Martin: I am not used to this. I want to thank all those who came forth to present today. When we suggested to the committee that we come to Sault Ste Marie, we knew there were folks here who had some very important things to share with us. I think it is important that this government get out to the whole province, particularly the north and Sault Ste Marie. It was good that you came forth, and I think today was a good example of government in action. I also want to thank my colleagues for deciding to come here, and to let you know how happy I was that you did and how much I enjoyed having supper with you last night.

The Chair: I am sure I am speaking on behalf of all the members of the committee, both those in the government caucus as well as those in the opposition caucuses, in saying that we have very much enjoyed the opportunity to be here in Sault Ste Marie today. We also enjoyed the hearings in Thunder Bay, in Ottawa and in London. We have had an opportunity to hear from people outside the centre of Toronto where the majority of our hearings have been held.

The committee -- this is for everyone's information here -- will begin clause-by-clause examination of these bills after the House reconvenes, which is September 23. We will likely be in the clause-by-clause process through the month of October.

If anyone has further information they would like to share with the committee, they should feel free to communicate with us in writing via the clerk of this committee. We very much appreciate everyone coming out today and sharing their views and observing our deliberations. I think, as I said, I speak on behalf of all the committee members; it has been a very productive use of our time. I feel the public hearings have not only been very productive but have been a very good experience for all members of this committee.

I would like to thank the staff who have come along with us both from the ministry as well as from the Legislative Assembly and look forward to the deliberations that will continue as we complete the examination of these bills. The meeting stands adjourned.

The committee adjourned at 1552.