Tuesday 16 August 1994

Long-Term Care Act, 1994, Bill 173, Mrs Grier / Loi de 1994 sur les soins de longue durée, projet de loi 173, Mme Grier

Ontario Home Health Care Providers' Association

Steve Haas, president

David Gooch, the past president

Allayne Evans, second vice-president

Ontario Coalition of Senior Citizens' Organizations

Dan McNeil, co-chair

Bea Levis, co-chair

Dian Goldstein

Senior Link

Judith Leon, executive director

Social Planning Council of Metropolitan Toronto

Peter Clutterbuck, executive director

Baycrest Centre for Geriatric Care

Dr Moshe Greengarten, vice-president, public and community affairs

Association of Allied Health Professionals

Catherine Bowman, executive director

Ontario Public Service Employees Union

Bob Reid, executive board member

Tracey Mussett, member, Local 477

Saint Elizabeth Visiting Nurses Staff Association

Laurie Clapperton, representative

Ontario Palliative Care Association

Shari Douglas, president

Connie Smith, vice-president

Victoria County Community Care

Val Barkey, executive director

Peggy Long, chair

Senior People's Resources in North Toronto

Bunny Segal, board chair

Barb Coupal, chair, long-term care committee

Bau St-Cyr, manager, home support

Jane Moore, executive director

Freda Finley, past president

Charlotte Maher, board member

Community Hospice Association of Ontario

Heather Balfour, executive director

Ontario Home Care Case Managers' Association

Marg Kovacs, immediate past president

Caroline Read, vice-president

Margaret Chiles, president

East York Health Unit

Michael Prue, mayor, East York

Dr Sheela Basrur, medical officer of health

Pat Thomas, director, adult health

Janice Leet, community health nurse


*Chair / Président: Beer, Charles (York-Mackenzie L)

*Vice-Chair / Vice-Président: Eddy, Ron (Brant-Haldimand L)

*Carter, Jenny (Peterborough ND)

Cunningham, Dianne (London North/-Nord PC)

Hope, Randy R. (Chatham-Kent ND)

*Martin, Tony (Sault Ste Marie ND)

*McGuinty, Dalton (Ottawa South/-Sud L)

*O'Connor, Larry (Durham-York ND)

*O'Neill, Yvonne (Ottawa-Rideau L)

Owens, Stephen (Scarborough Centre ND)

*Rizzo, Tony (Oakwood ND)

*Wilson, Jim (Simcoe West/-Ouest PC)

*In attendance / présents

Also taking part / Autres participants et participantes:

Ministry of Health:

Czukar, Gail, legal counsel, long-term care legislation

Quirt, Geoff, acting executive director, long-term care division

Wessenger, Paul, parliamentary assistant to the minister

Substitutions present / Membres remplaçants présents:

Jackson, Cameron (Burlington South/-Sud PC) for Mrs Cunningham

Malkowski, Gary (York East/-Est ND) for Mr Hope

Sullivan, Barbara (Halton Centre L) for Mr Eddy and Mr Beer

Wessenger, Paul (Simcoe Centre ND) for Mr Owens

Clerk / Greffier: Arnott, Doug

Staff / Personnel:

Boucher, Joanne, research officer, Legislative Research Service

Gardner, Dr Bob, assistant director, Legislative Research Service

The committee met at 1010 in room 151.


Consideration of Bill 173, An Act respecting Long-Term Care / Projet de loi 173, Loi concernant les soins de longue durée.


The Chair (Mr Charles Beer): Good morning, ladies and gentlemen. The standing committee on social development today continues hearings on Bill 173, An Act respecting Long-Term Care.

I invite our first witnesses to come forward, the representatives from the Ontario Home Health Care Providers' Association. Welcome. If you would be good enough to introduce yourselves for the members of the committee and for Hansard, please go ahead with your submission. We have received a copy.

Mr Steve Haas: I'd like to thank the committee for the opportunity of making a presentation on Bill 173, An Act respecting Long-Term Care. My name is Steve Haas. I'm the president of the Ontario Home Health Care Providers' Association and also a vice-president of Para-Med Health Services. With me today are David Gooch, the past president of the association and the owner of Community Homemakers in Mississauga; and Allayne Evans, who is a vice-president of Bradson Home Health in Ottawa and the second vice-president of the association.

Before we begin discussing the bill, I'd like to tell you about our organization and who we represent. The Ontario Home Health Care Providers' Association is the organization that represents commercial home care agencies in Ontario. Working through 115 offices across Ontario, our member agencies provide nine million hours of government-funded home care annually to seniors, disabled persons and children. Collectively we employ over 20,000 nurses, home support workers, occupational and speech therapists, physiotherapists and administrative staff. Approximately 40% to 45% of publicly funded homemaking services in Ontario are provided by OHHCPA members.

Our organization was founded in 1986 and has two primary purposes: to encourage excellence in the provision of home health care services and to represent member agencies regarding public policy issues affecting home health care.

It's our intention during this presentation to compare the elements of the legislation with the solutions that we, as experienced providers, propose for the problems in home care.

There is no doubt that changes are needed. Too often, home care can seem fragmented and uncoordinated to those who need care. We support change. However, Bill 173 doesn't reform the current system; it destroys it.

We believe that the imposition of multiservice agencies will be a step backwards, because instead of saving money it will be more costly than the current system. It won't be more responsive to consumer needs but rather less responsive because it is a monopoly.

We wish specifically to address the impact this legislation will have on people who need home care and workers in both the private and non-profit sectors and on businesses in Ontario.

Initially, it was this government's policy to restrict commercial agencies to providing 10% or less of all home care services. Effectively, this policy would have driven almost all our member agencies out of business. When the legislation was introduced, the 10% restriction was dropped and in its place was a 20% limitation on all providers, non-profit and private sector. We predict this will have a devastating effect on those agencies. Whether the restriction is 10% or 20% is not particularly relevant. Such a restriction will cripple an agency's ability to retain the critical mass necessary to survive.

I don't wish to dwell on the impact this legislation will have on businesses, but I would like to make a couple of observations.

The impact on businesses founded and developed by Ontario entrepreneurs will be disastrous. As a result of this bill, they stand to lose those businesses and thousands of our workers in Ontario will lose their jobs, and the international business community will have another lesson about the risks faced by private companies that do business in Ontario.

Interestingly, the threat of collapse also faces most of the current non-profit and volunteer agencies as well. Since the legislation mandates that the MSA manage the system and provide the services, current agencies will be swallowed up by the MSA. Gone too will be volunteer workers in the system. We expect that once the entire system is seen to be managed and controlled by government, volunteers won't donate their time.

Our concern today, however, is to convey not only the impact on our workers and businesses but equally the damaging impact of this legislation on home care consumers.

The Minister of Health states that the MSAs will bring one-stop shopping to the home care system. It will be one-stop shopping, because under this bill there will be only one place to shop. What it will mean to a person needing home care is that if the MSA does not meet his or her needs, whether those needs are clinical, ethnic, spiritual or linguistic, there is nowhere else to go. The consumer will lose all choice.

The great weakness of this legislation is that the MSA will be both the system administrator and a provider. It's an absolute monopoly without any motivation to serve the needs or wishes of consumers, who can't go anywhere else.

In an MSA, clients who are unhappy would have to report that dissatisfaction to the very same agency that decides the availability of services. Despite the government's plans for an appeal process, it isn't very difficult to imagine the fear a vulnerable person might have about daring to complain or speak out.

In the current system, clients who speak out can have their services provided by another agency. This is one of the positive features created by competition, something that will be totally eliminated by Bill 173.

Models like the proposed MSA have been tried and abandoned in other countries, notably Great Britain and Sweden. Other provinces, such as Manitoba, which have moved the private sector out of home health care, are now reversing their policies and want to reintroduce some form of competition in the provision of home care.

Therefore it is our recommendation that at the very least Bill 173 be amended by deleting section 13 in its entirety.

Dave Gooch is going to comment on some of the solutions we see as more effective than the proposed MSAs.

Mr David Gooch: I'm the owner of Community Homemakers in Mississauga and Toronto. My agency will be out of business when this bill takes effect. The employees will be laid off and the experience and expertise we have built up since 1975 will be lost to future home care clients.

There are two specific areas I wish to address in my remarks: the need for a coordinated information system and our opposition to the provincial government's attempt to manage the local day-to-day operations of the home care system.

Section 12 of the legislation defines which services the MSAs will provide, subject to funding restrictions and possibly waiting lists. The list is extensive but it is also restrictive. Subsection 12(2) prevents local authorities from providing additional service without the approval of the Minister of Health.

Second, as was mentioned previously, section 13 restricts local authorities from acquiring home care services from outside agencies.

These are two examples of how the provincial government is attempting to manage the entire home care system from downtown Toronto. We believe this bill ignores the legitimate autonomy that local administrators must have to meet the individual needs of local clients.

Home care administrators in many communities have challenged and in some cases are defying the government attempt to limit the private sector. Local authorities in Ottawa-Carleton, Hastings and Prince Edward, the Kingston area, Haliburton, Kawartha and many others have publicly rejected the government's non-profit preference policy. They have done so because they don't believe that a restrictive, non-competitive policy benefits their communities.

Our members have reported that there is considerable discomfort among local authorities across Ontario about this legislation, and we share their concerns. The OHHCPA believes that government should provide as much freedom to local authorities as possible. The Ministry of Health should develop overall home care policies, define core services, determine the level of financial resources that can be made available, then allocate these moneys to local communities so they can determine the priorities for home care.

The government can also play a central role in ensuring badly needed coordination for the entire system. As an agency operator, I am fully aware of the problems created by the lack of coordination among service providers. I believe the cause to be the absence of proper information management systems. An information management system would ensure that consumers receive appropriate and continuous care, from acute to chronic to long-term care. Instead of coordinating services, Bill 173 creates a total monopoly far beyond what is needed.

It is our view that had the government originally approached this entire issue from the perspective of filling the information and management needs of the current system, meaningful improvements would already be coming on stream and this legislation would be unnecessary. It is frustrating to watch government plan large-scale restructuring when comparatively minor changes would have succeeded better.

Finally, I want to state our belief that the cost of MSAs will be borne by future clients of home care in Ontario. The increased costs of an unneeded bureaucracy will come from the limited moneys available for home care services. Clients will in the end have fewer services.

Allayne Evans will elaborate on how consumers and workers will be adversely affected.


Ms Allayne Evans: Good morning. The 80%-20% restriction on contracting out will mean that many people will be out of jobs, trying to find a job in a health care system that has severely been constrained in the last few years. Their experience and their training in the delivery of home care will be lost.

The majority of people who work with me are women. Many of them are new Canadians and they're concerned about their futures. This legislation makes no commitment to them for any future employment whatsoever. It's not just commercial employees who will be vulnerable to lost jobs. Workers in the non-profit agencies will have the same fate.

Throughout these hearings, I hope that some of the front-line workers will come to this committee and explain what they're going through, but many of them think that if they make public statements, it will hurt their chances of finding employment in the MSA of the future.

I don't run a large company; it's a local business with local workers. Many of the home care agencies that make up OHHCPA are owned and operated by women. The services we provide are meeting the needs of consumers. Quality is not an issue and never has been. If we don't maintain a high quality of service, we lose contracts to other agencies. Competition is the driving force ensuring quality.

One of the reasons the commercial sector has enjoyed success in the home care field is because of our innovative ideas. We've moved into other areas where other agencies weren't providing care. We began providing care 24 hours a day, seven days a week, holidays included. We did this to provide care to clients to meet their needs and not the needs of a bureaucracy.

Commercial agencies have exactly the same funding from the government as the non-profit sector. Studies have shown that we pay our workers the same as those in the non-profit sector. There has never been a concern about the quality of care delivered by either sector. To the government, it should make no difference who is providing the service. We've heard the Minister of Health say that funds should go into care and not profit, but there's nothing -- no research, no studies -- that shows that non-profit agencies deliver better care than commercial agencies. The government pays the same rate for service regardless of who provides it.

For me, running a home care agency isn't about profit, it's about people. Our business is care giving. We've succeeded because we provide services to people in a caring way. Our clients rely on their care givers. A positive, supporting relationship between a client and a care giver unquestionably contributes to their wellbeing. These are vulnerable people sometimes and they look forward to the consistency in their care provider. We know from years of experience that clients don't like arbitrary changes, and they never hesitate to inform us of what they don't like. I don't believe that an MSA will provide the responsive, flexible service that consumers need.

Under Bill 173, any degree of consumer choice, local autonomy and creative response to client needs will be lost because consumers won't risk complaining or asking for changes for fear of losing what they already have. They will know that the same people they complain to not only provide their care but decide whether they get care at all.

In a letter to the minister, the board of health in Kingston explained why it opposed limitations on commercial providers: "The board is concerned that it is already starting to see the not-for-profit providers start to attach restrictive provisions to their services. This results from the creation of near monopolies among providers. Such a restriction in service is in addition to the restriction in quality which results from the disruption of continuity of care."

We could haven't said it better ourselves, or with as much authority.

This legislation goes far beyond the needs of the consumer and will, in some areas of the province, reduce the level and quality of service provided to the people of Ontario.

Mr Haas: I think we've made it clear that the Ontario Home Health Care Providers' Association opposes this legislation and the implementation of MSAs. We are, however, not opposed to reforming the home care system. We have recommendations that would bring about reform without creating yet another massive bureaucracy.

The government should determine what services it can afford to provide and then fund those services in an equitable and consistent fashion across the province.

Local communities should ensure that services are provided as efficiently and effectively as possible through managed competition among all providers.

Consumers should have much more choice in the services they receive as individuals rather than having to fit into specific programs.

The development of a client-focused information system which coordinates community and facility care must be a priority.

Our last recommendation: The government must give local communities responsibility to allocate resources at the local level in response to local needs. The Ministry of Health must stop trying to manage day-to-day operations of home care.

We've offered some positive suggestions on ways the home care system can be improved to meet the needs of consumers while maintaining the essential qualities of the current system, such as competition, consumer choice and local autonomy.

It's our sincere belief that Bill 173, in its current form, will strip positive qualities found in the current system. The ultimate victims of the proposed system will be home care consumers, who will have far fewer services and less choice.

Thank you for listening, and we're happy to answer any questions.

Mr Gary Malkowski (York East): Thank you for your presentation. You have stated that you would lose great numbers of employees because of the expansion of long-term care. We feel these will be picked up, anyway, by the MSAs if people are displaced. But we don't think it's the case that you would lose a whole lot, because it's my understanding that a lot of your funding comes from private dollars and I don't think the changes with long-term care really affect you at all. Could you comment on that?

Mr Haas: My response would be that the system as it exists today has our companies providing a small amount of private services in addition to a significant amount of government services. We won't have the critical mass, as individual agencies, to survive, any more than the non-profit agencies will have the critical mass necessary to survive the limitation on contracting out.

Mrs Barbara Sullivan (Halton Centre): I appreciate this presentation. I'm astonished, frankly, at the last question from Mr Malkowski, because I think it's clear that he doesn't understand, first of all, the position now of the commercial sector in home care provision, which is close to half of all home care provided in the province; nor the devastating impact of the removal of government-funded contracts, I suppose, for home care. In fact you will be put out of business, and there is no compensation contemplated for the loss of your capital, for your operation, for any physical facilities you own and so on, nor for the time and energy that's been put into the operation of your businesses. There is no indication in any publication, in any study, that the services your members have provided are of any lesser quality or any less evaluated than the non-profit or public sector services that are provided, so I'm just astonished at that.

I'm quite interested in the last points. You talk about a funding basket, a basket of services that the government should determine should be made available. I think the government has done that in this bill in the definition sections of what are community services etc, professional services. What is not included in this bill is a guarantee that those services will be provided, because of the funding.


Once again we've talked about raised expectations. I'd like to know what action you see your members taking with respect to compensation for your lost investments and how many of your members you think will be completely out of business, therefore leaving people who would not be using the public system for home care at risk or without services.

Mr Haas: I could begin the answer by saying that with regard to the compensation, we didn't mention it and didn't feel we had to because it doesn't specifically relate to Bill 173 at this point, but we did initiate a legal action against the government with regard to compensation and we will continue that.

Mr Gooch: With respect to the impact on our industry, there is an error on the part of Mr Malkowski in his understanding of the private sector and of the nature of our businesses. In most cases, and in the case of my agency over the past 20 years, our growth has been through our involvement and our cooperation with local home care programs in Peel and Toronto to the point that 70% to 80% of what we do is to provide services to those programs, and that is fairly typical of private sector agencies across the province.

It's not hard to imagine that any agency, whether it be us or whether it be Red Cross or Saint Elizabeth, that loses 70% to 80% of what it does would be at serious risk. It's hard to imagine that we would be able to continue to provide services. We don't really have an estimate, but it certainly represents the majority of private sector agencies across the province that would find themselves in the same position.

Mrs Sullivan: Have your discussions with the government led you to any conclusions with respect to the labour adjustment policies that might be put into place so that employees who are currently employed by what will now be defunct companies will in fact find work in the MSAs?

Mr Gooch: We've stood with the non-profit sector, with the Red Cross, Saint Elizabeth and VON, in meetings with the minister's staff in asking for guarantees for the protection of jobs for our workers. We've also negotiated, through the development of HSTAP, the Health Sector Training and Adjustment Panel, for the same type of protection for our workers, but we have not been able to get that type of guarantee. Obviously, as you see in the legislation, there is no protection for our workers who find themselves in an open, competitive market for jobs once the restructuring takes place.

Mrs Sullivan: Is it your sense that there is protection, or at least a promise of protection, for workers who are union members?

Mr Gooch: We have faced in our discussions at HSTAP and in other places where unionized workers have requested protection for their workers to be guaranteed in the community sector, which places our workers in the back seat looking for jobs in that sector. Yes, we've heard at all levels of government that same sort of promise.

Mr Jim Wilson (Simcoe West): Thank you for the presentation. It's kind of déjà vu all over again. We went through much of this with Bill 101 with the government trying to drive you out of business. It's just that this time -- and everyone in the room should know this, and particularly the Toronto Star should know this, because in today's Star there's a rather God-awful article, by Bill Walker, that didn't reflect yesterday at all.

Mr Larry O'Connor (Durham-York): The word is "negative."

Mr Jim Wilson: I'll have a little chat with Bill because it certainly didn't reflect what was heard here yesterday. None the less, the government this time has also decided to put the Red Cross and VON and the non-profits out of business, or at least out of the way they're currently doing business, with their volunteer boards. Why? I don't know, other than, I suspect -- Mr Quirt, for example, when he spoke to the committee yesterday, talked about the 70,000 people they consulted, and the government says it heard through that consultation that people wanted one-stop shopping. I went to one of those meetings and people simply wanted one phone number to contact in their local community and they wanted a knowledgeable person at the other end of the phone. But then Mr Quirt went on to tell us that those 70,000 people, the majority of them, also wanted the MSAs to deliver the services.

That's very clearly, though, a government spin on what they heard, because I don't recall anyone in the many, many meetings I went to, particularly in my own community, assuming that the government was going to take over the delivery of services through MSAs, and MSAs are government. They're government-appointed, much like large parts of our DHCs, and the government in a sense is setting up a monopoly on this system.

You talked quite correctly about competition and the evolution of your sector, that you were there to respond to the off hours, were there to respond in areas where other agencies' services at the time weren't available. You didn't grow up through any master plan of government; in fact I think you grew up, through three different governments now, because there was a demand there from consumers, and nothing else.

The consumers we've spoken to, which would number in the thousands over the past three years, all still expect that the Red Cross and Dynacare and private sector service providers are going to continue to provide those services. They don't know what this legislation's about.

You mentioned you hope your employees come forward. I hope employees come forward too, because we know this government's capable of changing its mind. When 4,000 employees of the auto insurance sector appeared at Queen's Park, the government soon backed down, especially when the secretaries and the people who aren't corporate executives appeared at Queen's Park and said: "Get out of my life, government. You're ruining it and now you're going to end my job," and told this government to take a hike.

I would tell your employees, and I will do everything I can to ensure that they understand the implications of this bill. There is no job security. There are some rumours that perhaps unionized employees will have some job security, but I doubt it. I think the government has a moral obligation to provide job security to everyone.

I want to leave you with the thought that, very clearly, the 80-20 rule will go the way of the government's Bill 40 job-killing labour laws if my party forms the government in the next 12 months. There is no hesitation on our part whatsoever. The problem is, and I want you to comment on this, that the 10% rule was a policy statement by the government, something concocted in cabinet. This darned legislation has the 20% rule actually put in the legislation, which means any government, the next government -- certainly all indications are right now that it won't be the NDP government in the next 12 months -- has to go back to Parliament, which becomes a lengthy process of undoing all this social engineering the government has done. But I assure you we will go through that process and we will undo what they've done.

I also want to make sure people are aware that when you get into the regulatory section, it's not just an 80-20 rule. If you look at the regulatory section, paragraphs 56(1)37 and 38, the government can also prescribe rules in addition to those contained in section 13, section 13 being the 80-20 rule, "respecting purchases of services by approved agencies from other service providers;" and 38, "governing the relationship and the contracts between an approved agency and any person from whom it purchases community services."

Just one last thing: As you know, where this leads -- and the public should understand this and the non-profits should understand this. I brought to the attention of the House before it adjourned the case of a new non-profit home care agency that was told by the government that it could not -- for example, it was contracting services with a private firm for intake services and assessment. It eventually boiled down to the fact that because that was a percentage of approved budget -- they had hit their 10% mark -- they therefore couldn't buy pens any more from Grand and Toy, they couldn't go out and buy bandages from a medical supply company. They couldn't do anything with the private sector because they had hit their 10% of approved budget. Now that arbitrary figure has been moved to 20%, but it basically put them right out of business just overnight, and we couldn't get the government to budge on it whatsoever. I think the public should understand that when it says 20% of approved budget, you're screwed in a variety of ways. You're out of business.

Mr O'Connor: Mr Chair, I hope you're going to allow an opportunity for my colleague to speak.

Mr Jim Wilson: I just want you to comment on that, because it's not just the draconian section of section 13 where it says 80-20, but also should the government, as in the case of this one new non-profit -- it took a dislike to it and used the regulatory authority to just put it out of business, and it was extremely unfair. I'll give you an opportunity to comment on that.

Mr Haas: I would want to add to what you said about the consultation process. The only written report we ever saw on the consultation process was from the Peterborough area office -- 5,200 people responded in their area out of 75,000 -- it reported that the conclusion on what the then service coordination agency should do was purchase service from profit and non-profit providers to enhance quality assurance and competitive pricing.

Ms Evans: I'd like to respond to the 80-20 comment: 80-20 or 90-10, they're arbitrary figures. Where do they come from? What do they represent? What they mean to us is that we will be out of business and our employees will be out of jobs, and I think that's the best answer I can give you to the 80-20.

Mr Jim Wilson: Just as a point of information: We did ask the government yesterday where it came up with the 20% figure, and it's unable to show us any documentation whatsoever.


Ms Jenny Carter (Peterborough): I must say I don't recognize the bill that I see when I listen to some presentations, because what we have here is a consumer-oriented bill. It's set up to give the best possible service to the consumer. It's not a bureaucracy, because it's based on the local community. The people who run this are going to be locally elected boards --

Mrs Sullivan: Elected?

Mrs Yvonne O'Neill (Ottawa-Rideau): Appointed is the word.

Ms Carter: -- very similar to some already there in the field, and as I say, we're definitely not setting up a bureaucracy.

Now, I'm concerned about this question of jobs and pay. I must say that the Tories are certainly not people who ever protected the rights of immigrant homemakers --

Mr Jim Wilson: In 42 years we did a heck of a good job of it. It's a much better province.

Ms Carter: -- or that they did a great deal for pay equity. But the question I'd like to ask you is, commercial providers, as you say in your presentation, are paid the same rate as not-for-profit providers for the services they give. Now, although you have said that your workers are just as well off and that your services are of equal quality, the profit must come from somewhere. I'm just wondering where that profit margin is actually found. Is it lower wage rates, or does it come off the quality of care?

Ms Evans: We pay the same wages as the not-for-profit sector. If we didn't, our employees would go there. It's easy to do; they're located everywhere. We have to be competitive with wages with our employees, and we are.

The issue of quality: That came from Ruth Grier herself in June 1993, when she stated categorically that quality was not an issue in this 90-10, the original. That's not just coming from us; that's coming from the minister herself.

The issue of an MSA not being a bureaucracy? I don't know how to argue that to you other than what we've done. I see that it will be a huge bureaucracy, with what's called the basket of services being dictated by Queen's Park. It may be run through the district health council and the long-term care area offices, but it's Queen's Park that is saying what will go into this basket of services. It's not my local district health council deciding, and it's not my local home support agencies -- non-profits; we talk all the time -- who will decide what is needed in their communities. It's Queen's Park that will decide.

Ms Carter: There's going to be an envelope --

The Chair: I'm sorry, we're going to have to call that a close. We're over the time. I know we could go on for a while, but we do have other presenters this morning. Thank you very much for coming.

I call the Ontario Coalition of Senior Citizens' Organizations.

Mrs Sullivan: On a point of order, Mr Chairman: While the next group is coming forward, I wonder if the parliamentary assistant could clarify. Ms Carter has indicated to the public hearing that the boards of MSAs will be locally elected. That's not found anywhere in the legislation, nor has it been described in those terms by the minister nor by anyone else, as far as I know. In fact the creation of the boards is something of a mystic process. I wonder if the PA could describe how these boards will in fact be set up.

The Chair: Very quickly, please.

Mr Paul Wessenger (Simcoe Centre): I think I will ask legal counsel to indicate, refer to the sections of the act. That probably is the best way to clarify it.

Ms Gail Czukar: The definition of "agency" in the bill is where you find that. The MSA is an agency that's been designated by the minister. It first has to be an approved agency. The definition of an "agency" is a non-profit corporation under the Corporations Act which is an independent corporation that is formed by local community people and which develops its own constitution and bylaws, which can be approved by the minister and which will be filed with the minister and reviewed and approved.

We also have the power in the bill to prescribe particular kinds of bylaws, if necessary, in order to ensure that it's an open membership to allow an open membership to elect the boards and to ensure consumer representation on the boards. That's where the locally elected provisions are found: section 2 and sections --

The Chair: I'm really going to have to intervene here. I know we can get into a discussion of some of these things but we've got --

Mr Jim Wilson: Except, Mr Chairman, that can't go unamended.

The Chair: Okay, very quickly, please.

Mr Jim Wilson: It doesn't say "elected." What they're telling us is that in the regulation, using the regulative authority here, that's what they're going to do. Could we have that in writing, exactly what you -- in fact, give us the regulation, if you've already got it written.

Mrs Sullivan: And is it elected from within membership?


The Chair: Okay, can we --

Mr Jim Wilson: Because so far --

Mrs Sullivan: Who qualifies to be a member?

Mr Jim Wilson: That's unfair. I mean, obviously they told you people it's going to be elected. I want that as a public --

The Chair: Order.

Mr Malkowski: Maybe you finally learned something over there. So much for your homework.

Mr Jim Wilson: How can we do homework when we don't even know what the regulations are?

The Chair: I think if we can come back to that, the question is on the table, but we do have witnesses who are here this morning. I want to make sure that we hear from them.


The Chair: Our next witnesses are here, the Ontario Coalition of Senior Citizens' Organizations. Welcome to the committee. If you'd be good enough to introduce yourselves, we do have a copy of your submission, if you would please go ahead.

Mr Dan McNeil: Good morning, Mr Chairman and members of the committee. My name is Dan McNeil, co-chair of the Ontario coalition. On my left is Bea Levis, our other co-chair, and on my far left is our director of operations for the coalition, Morris Jesion.

The Ontario Coalition of Senior Citizens' Organizations, OCSCO, would like to thank the standing committee on social development for the opportunity to present our views on Bill 173, An Act respecting Long-Term Care.

First, we would like to acquaint you with our organization. The Ontario Coalition of Senior Citizens' Organizations is a seniors' organization dedicated to providing an opportunity for seniors to become involved and participate in society. OCSCO acts as a forum to bring representative groups of seniors together to share information, raise issues of common concern and engage in group activities related to those concerns. For instance, our organization has dedicated much of its time and effort into long-term care reform. OCSCO, in conjunction with the long-term care alliance, has worked to give seniors a voice in the long-term care reform debate.

The objectives of OCSCO are to represent and speak on behalf of its member organizations on issues identified by the coalition; to provide a forum for senior citizens' organizations and other relevant bodies; to share information on matters of common concern; to educate and research on issues identified by the membership; to provide the government and community with a broad, organized channel of communication to the senior citizen community; and to consult with government and/or other groups.

OCSCO's membership consists of 66 organizations, representing more than 500,000 seniors across Ontario. On matters affecting the quality of life of the senior citizen community, OCSCO unites both large and small groups from community, union, ethnocultural groups, natives and veterans' organizations. OCSCO member organizations include the Older Women's Network, the Federation of Italian Seniors, the United Steelworkers of America Retirees, Ontario Public Service Employees Union, Toronto Mayor's Committee on Aging, the Older Adult Centres Association of Ontario, Canadian Pensioners Concerned and the Federation of Francophones of Ontario.

Ontario's long-term programs have been undergoing reform for many years. Health and social services in Ontario have been characterized by increasing financial cutbacks, staff layoffs, an unequal distribution of services across the province, closure of beds, a fragmented and uncoordinated component at the community level and a lack of strong linkages between institutional and community care services. Thus, long-term care in Ontario has become an inefficient and poorly managed system.

Bill 173, An Act respecting Long-Term Care, is fundamental to improving this ailing system. Bill 173 will ensure that a wide range of community services are available. It is intended to improve the quality of these services and to simplify and improve access through multiservice agencies. It proposes to develop a proactive approach to try to encourage local community involvement. Long-term care reform will shape the delivery of services to Ontario's seniors and the physically disabled in Ontario.


Overall, Bill 173 is intended to create a system of care that is coordinated and responsive. This legislation aims to reduce fragmented service delivery, as opposed to a multitude of agencies as is currently the case. However, while this vision of a new long-term care system has been in existence for numerous years, there is a deeply rooted concern that there won't be enough money to fulfil it.

OCSCO is pleased with the ministry's commitment to review long-term programs in Ontario. We support the following initiatives and principles in Bill 173: a single entry point to access services to the MSA, a continuum of services, a high quality of service, racial equity and cultural sensitivity, flexibility in MSAs and, of course, consumer involvement.

I would now like to turn the rest of this over to our co-chair, Bea.

Mrs Bea Levis: There are 11 areas of Bill 173 that OCSCO would like to comment on.

(1) The MSA is one of the most important components of the system. The MSA will be the single access point of entry to the long-term care system. This organization will provide numerous services, such as community support, homemaking services, personal support services and professional services. For those services the MSA can't provide, there will be information and referral service available.

This one-stop shopping centre is to cover a basket of services. However, not all services are mentioned in this legislation. Important services like attendant care, supportive housing, services for the blind and for the hard-of-hearing are not mentioned in Bill 173. OCSCO is concerned that there does not seem to be a rationale for covering some services in the legislation and addressing others in the regulations or completely leaving some out. Therefore, OCSCO would like to recommend that there should be some rationale and flexibility when outlining the services the MSA is responsible for.

OCSCO feels that this legislation is too detailed. As is often the case, it is more appropriate to have the operational details of this reform in the regulations.

(2) Financing the MSA and fee for service: The government will have to ensure that the MSA is continually financially strong. OCSCO sees the potential of an MSA not having enough funds to cover the concerns and needs of its geographic area. There must be a safeguard in the legislation against this. MSAs need secure budgets. No individual should ever be refused a service due to budget cutbacks, fiscal restraint or the inability to pay. Being on a waiting list means no service. Even under the legislation where some services have a fee, there must be a mechanism in place to make sure that the consumer gets the care and service he or she needs. The issue of fee for service must not lead to any kind of means testing or targeting. User fees are counterproductive and this type of social planning is demoralizing and a disincentive for service.

The distinction that is made between homemaking and community support services, where there is a fee, and between professional and personal support services, where there is no fee, is confusing. Seniors will need to prorate time and user fees, particularly if it is the same worker. This is complex and opens the door to implementation of new user fees. OCSCO is strongly against any form of user fees.

(3) Assessment: The appropriate role of the registered nurse and the medical doctor in the assessment phase needs to be outlined. It is important that these professionals must be acknowledged and utilized in the assessment phase and in other areas as needed. Furthermore, the consumer must have as much input into this decision-making/assessment component of their plan of treatment and changes in service.

The right of consumers to make their own choices for which services they wish to receive is often taken for granted. Bill 173 must ensure this right of choice when determining which services in the community, at home or in the institution the consumer requires.

(4) Governance: According to Bill 173, the boards of the MSA will include consumers. OCSCO has often found that seniors are often token representatives. The consumers or seniors are often not part of the decision-making process and often feel that their voices are ignored. When developing the boards and committees of MSA, it is important that the consumer will be given equal representation. In OCSCO's opinion, this would constitute the consumer making up half the board or committee. This consumer should be an individual who is or will be in a position to receive long-term care services. The user/consumer must always be directly involved in the governing and driving of this proposed new system in policy-making and in programming. This would constitute a more equitable system for all who use it. There needs also to be a strong representation from the social services, in addition to the health services sector.

The MSA must be made accountable to the local community. They should be required to have open meetings of the boards, hear deputations and make records available to the public.

(5) Appeal process: Primary care givers, those who care for a frail, sick, elderly or chronically ill family or friend in their own homes, presently have nowhere to go to appeal unjust decisions made by service providers and home care regarding inadequate, inappropriate services or any other forms of grievance. The government must establish an independent review board where primary care givers, the recipients of care and their families may appeal without the fear of repercussions.

(6) Bill 173 has no enforcement mechanism to guarantee that the consumer is getting the best care and services possible. Similar to the standards regarding institutions, Bill 173 must ensure that program supervisors or advisers visit the consumer's home frequently to make sure he or she is being cared for appropriately.

(7) The providers: As we all know, there is a direct relationship between the quality of care and the quality of work. OCSCO is concerned about the lack of regulations for the service providers, the hands-on workers. There has been an increasing number of workers providing specialized care who are scarcely trained or not trained at all. This puts the life of the consumer in jeopardy. Service providers, mostly women, must come under the strict regulations and guidelines which should include proper pay scales, pension plans and other benefits. The increase in unregulated, non-professional care for the elderly and disabled is an evident problem. The generic worker is also of concern. This single occupational designation for community-based workers -- a jack of all trades -- will result in problems in care and service.

(8) Respite care: In a time when caring for an ill or frail family member is often pushed on to one's family, there is no recognition for respite care. Respite care, a support for the primary care giver, in particular is an important factor in the consumer's aim to age in place. This issue has been systematically ignored in previous legislation dealing with health and social services. Primary care givers work long and hard hours and often need a break. An initiative often discussed is the availability of unused hospital beds for this type of relief or support. Respite care should be provided at no extra cost to the families of care givers for as long as they need it.

Primary care givers must have support. In particular, there should be a contingent emergency plan for those providers who are either ill or get injured while providing care. Government must recognize that these workers, mostly women, dedicate their life to caring for an ill family member. To most, this would be considered a full-time job. Therefore, these workers should be paid for the services they provide, get reimbursed for out-of-pocket expenses and receive benefits. There should be a clear and concise section in Bill 173 that covers respite care and payment of services delivered by the primary care giver.


(9) Convalescent care: Over the last few years there has been an abundance of patients who have been discharged from acute treatment hospitals quicker and sicker than ever before. These individuals are discharged without arranging for the appropriate in-home care services. These seniors are falling through the cracks. Bill 173 must ensure that home care programs are in existence before the senior gets discharged. A quick response team would be an asset. Another option is to increase the number of beds for transitional and convalescent care either within existing hospitals or in any other care facilities.

(10) Preventive health care: Bill 173 fails to recognize the importance of preventive/wellness programs. For seniors, the social, psychological, recreational, spiritual and many other aspects of senior centres are necessary in order to promote the optimal level of independence and decrease the level of dependence. Seniors use older adult centres and school board programs, to a name a few, to keep themselves physically and mentally active in the community. These programs need to be recognized and funded appropriately in order for seniors to be healthier.

(11) Volunteers: The issue of volunteerism in long-term care services for Ontario must be supported and encouraged. To show support of this very important program, there should be a way to fund out-of-pocket expenses for the volunteers. Many seniors find this a deterrent to volunteering for such programs as Meals on Wheels and transportation. There must also be a volunteer coordinator at all MSAs to maintain and enhance this very important program.

We would like to make one last comment: the funding for this new system. When long-term care reform was in the developmental phase, all players came together on one important point, namely, that the needs of the consumer should come first. This vision has since been lost because many say it is too expensive. We do not want to lose our sense of caring, compassion and understanding.

Governments have again and again stated there is not enough money to fund the vision of an accessible, equitable and high-quality care long-term care system. Government does in fact have the money to put into Ontario's ailing long-term care programs. It is a matter of priority. Recently the government promised over $60 million to a new trade centre. A government which is supposed to stand for social justice but seems more concerned about building trade centres and highways has lost that vision.

In closing, OCSCO is pleased that the government is taking a proactive approach in long-term care. We feel this legislation makes for a strong beginning to reform Ontario's long-term care system. As we know, the status quo is no longer a viable option. Today's seniors want to maintain their independence and dignity. The quality of life and care must remain the centre point of long-term care. Together we must design a system which will improve any inefficiencies, produce higher-quality care and, particularly, become more consumer-sensitive. Consumers must be assured that the government is willing to move rapidly to implement this long-term care reform.

The Chair: Thank you very much. Just before turning to questions, if I could say to members, we are a little tight and I'd ask you to try to have your question in one, if you might, and we'll begin with Ms Sullivan.

Mrs Sullivan: I'm interested in many of the points that you've raised in your brief. I note for the record, for instance, that you've underlined the importance of the clinical assessment of the person who is seeking long-term care and that you've raised questions about evaluative mechanisms that are available for the home care agency, which will become the MSA. You've raised issues about the generic worker that I think we'd like to pursue at another time, if the Chair would make a note of that.

You've made comments with respect to respite care, and I note that care giver support services are included in the basket under community support services. What seems to me then would happen is that from time to time a care giver who needs a break would have an opportunity for community support through that mechanism.

The point that you've raised, however, is, what if care givers become quite ill or incapacitated themselves, which is a very frequent circumstance. We frequently have two people who are living together, both frail, perhaps one ill, and when the second one becomes ill, there are increasing problems.

You've called for a contingent emergency plan to ensure that the care giver himself or herself receives urgent support. Have you placed that before the government, and how do you see that being involved, say, in a statutory way? Do you see that should be required as part of the basket of services, or do you see that as something that should be allowed for in regulations, or do you see that as something that would be more carefully and better defined by the local agencies?

Mrs Levis: Well, I think probably a combination of all of those on your last point. I think it's important that some sort of a clear guarantee exists -- and whether it should be in the legislation or in the regulations I'm not quite sure -- that care givers be given immediate support when they break down, when their health breaks down and they can no longer continue.

We know from experiences when we were preparing this brief, there was a case of a care giver who was very, very ill, and she had to fight and use influence, which she happened to have, in order to obtain any kind of care. It's that kind of thing, and her point was a well-taken one: What if there were, as there are, people who don't know any MPs, who don't know any MPPs, who don't know any of the inner circle? What then happens to these people?

We want to make sure that somewhere along the line, whether it's in the legislation as a general sort of guarantee, and certainly in the regulations, there be that kind of response, that they are entitled to getting care immediately.


Mr Cameron Jackson (Burlington South): I want to thank your organization for a comprehensive brief. You've covered quite a bit of area here, but the general tenor of your brief is supportive. That causes me to raise some questions because, a year and a half, two years ago when the second phase of long-term care reform was before a committee and your organization endorsed Bill 101, we found out that access to chronic care was no longer guaranteed as of right in Ontario. It was removed from the Ontario Health Insurance Act.

We found out that the fee adjustments that everybody talked about in very romantic terms ended up costing seniors $150 million of increased user fees. Many seniors' organizations wrote to me after Bill 101 and said: "Look, we were betrayed by the government. We were betrayed." Quite frankly, all the same players are here from two years ago. Every single one of the players is still here.

My question is, given now that this bill is going to do the same thing to home care, remove it from the Ontario Health Insurance Act, an as-of-right issue -- your brief speaks very clearly about access points and making sure that there are guarantees. How can you support legislation which in it causes the universal right of a senior citizen in Ontario to access a service where fundamentally the outcome is the state says, "Well, look, we just don't have the beds," period, end of sentence? It doesn't have anything to do with your assessed needs being met or whether you're being discharged from the hospital prematurely and with a lingering illness. Basically the state is now positioned to say, "That's not our responsibility because we just don't have those beds."

Do you have the same faith and support for these approaches that you did two years ago or, as your correspondence and other organizations have indicated, are you a little more concerned about the real agenda here and the real outcomes? Because the experience of Bill 101, with its impact on nursing homes and homes for the aged, was a horrendous increase in user fees and the removal of its access point as guaranteed in the Ontario Health Insurance Act.

Could you please respond to that, because all of this is academic if in fact the government has set a pattern and a direction that will be similar to the one we experienced after Bill 101 was implemented, because it was the long-term care bill as well.

Mrs Levis: I think what we're asking for here is that there be absolute assurance in the bill that this will not happen. What we're asking for is that the right of a consumer to service, whatever that service happens to be, will be ensured. As far as we are concerned, while we accept the basic idea -- because in all of the pre-consultations and so on in local areas consumers want an end to duplication and to the rigmarole of having to chase here and chase there and then not know where to get all the services. We want one access point for all the services, and I think most consumer organizations are absolutely agreed on that point. What we want, however, is an additional assurance in this bill that the right to service is guaranteed.

Mr Jackson: So your position is that you do not support the removal of home care services from the Ontario Health Insurance Act as proposed in this bill; that should not be delisted from the OHIP benefit schedule. The minister yesterday said that there are only two provinces in Canada that have it guaranteed in their legislation. She felt there was nothing wrong with removing it.

Mrs Levis: This is something that, I'm sorry, we have not taken into consideration at all in preparing this brief.

Mr Wessenger: Thank you very much for your brief. I always enjoy hearing your brief because it's very good to hear from a consumer perspective with respect to the legislation. I think the point you make is very valid, that really the whole question of services has to do with funding and that if the funding's not there, the service won't be there. Certainly the government has from, say, 1990-91, spent $550 million on long-term care in the community and by 1994-95 we're going to be spending over $1 billion, and I think that's a substantial increase in investment in long-term care.

My question, really, what I'd like to ask you about, I was very interested in your comments with respect to governance. Certainly we in this committee are looking for a way to ensure that the MSAs are both accountable to the local community and at the same time have real consumer representation, and you certainly indicate you support that thrust, but I was wondering if you have anything more specific in the way of suggestions of how we might ensure, when we're structuring these MSAs or providing guidelines for them, that we have more real consumer input.

Mrs Levis: Well, I think the section on governance really makes a major part of our recommendation, that the consumer representatives on any boards or any committees that are appointed be what we call real consumers, that is, not representatives of an agency that is serving consumers or representatives of a hospital board, which has happened in some local smaller communities, but people who are in a position to receive the services or are likely to in the next unmentionable period of time. I don't know of any other way to ensure this, other than having a large number of consumers on every board and committee.

Mr Wessenger: So you're really looking at the aspects of ensuring that the majority of the members are not there because of their provider position, that they actually come from the public then, not in the sense of putting further restrictions like saying so many senior reps or so many people with disabilities or something of that nature?

Mrs Levis: That's right.

Mr Wessenger: Fine. Thank you.

The Chair: Thank you very much. I know there are other questions.

Mr O'Connor: Mr Chair --

The Chair: I'm sorry, we have to move on. We're very tight for time. I want to thank the coalition for coming and invite our next witness, Miss Dian Goldstein.

Mrs O'Neill: Mr Chair, on a point of order, please.

Mr O'Connor: The request that I have, Mr Chair, is if our presenters had any thoughts on the bill of rights, maybe they could submit them so we can have that included in the package. Their presentation was so well put together I thought maybe some thoughts they might have on the bill of rights would be appropriate.

The Chair: You can discuss that with them privately after as well.

Mrs Levis: We can certainly do that. Thank you.

The Chair: Ms Goldstein, if you would come forward.

Mrs O'Neill: Mr Chair, on a point of order: I am the critic for seniors for the Liberal Party and I take great offence to the comment that was last made by Mr Malkowski. I think I want to request in writing, and we have a right to -- there is confusion on this bill. There is also a misunderstanding on this bill. The last presenters stated that; many presenters yesterday.

Two things I want clarified from the government's perspective. Maybe they haven't even got the answers. Mr Wessenger's question kind of indicated that to me.

The bill of rights is stated by the government to have choice within it. I've read it and read it and reread it; there's not one word there that even recognizes choice or says choice in it. If there are choices there in other words, I'd like to see them.

Community-based boards: I'd like to know how the board is going to be community-based when the actual act says:

"The minister may impose terms and conditions on a designation made under subsection (1) and may from time to time amend or remove the terms and conditions or impose new terms and conditions."

If that isn't centralized designation of agencies and boards, then I don't know what is. Now, if I'm missing some guarantees, it's because I haven't been able to find them, and I have met with endless groups of seniors this summer on this bill.


The Chair: Miss Goldstein.

Ms Dian Goldstein: Thank you, Chairman and members of the standing committee. It's good to be back here once again and see all the familiar faces.

Of course, I'd like to congratulate this government on moving ahead with long-term care reform with this legislation, and particularly, as you mentioned, Larry, for including a bill of rights and an appeal process. Legislation for community services has not ever been available in Ontario and I think they've talked about it since 1954. So although we may have a few criticisms about it and want to see some changes, I want to congratulate the courage of this government for getting it on the table.


You're hearing lots of details and lots of opinions and lots of ideas, and right now I'd like you to just close your eyes and sit back and enjoy an image, whether you will enjoy it or not, of the kinds of people that Bill 173 should serve. This poem is called Grandma Sits Down.

Her knees lean against the front of the battered rocker,

getting their bearings, while she frowns out the window

at the garden, or squints into the poplars

to see if the sparrow-hawks have returned. Slowly,

flat-footedly, like a fashion doll in the department store,

she rotates, knees locked, keeping contact

with the chair. Her hands grope for, find, grip the knobs

at the ends of the wooden arms. She's not looking

at anything now, it hurts, she's concentrating.

Holding her breath like an astronaut, knuckles white

around the knobs, she lets herself fall.

The chair shudders, reels backwards, hangs

for a very long instant on the coasters' rims (her eyes

are shut, head pressed back) and then begins to oscillate.

She breathes out: Another successful manoeuvre, nothing

to be especially pleased about. She knows

not to take for granted she can get back up. Still,

the wind of her motion cools her cheeks. She continues

with the letter she's been writing: "The earth is beginning

to thaw. I am anxious to plant some seeds."

Do remember in these hearings that you are going to be hearing mostly from providers, who may have turf to protect, who may be worried about their own power and control. I refer primarily to many of the professional agencies, who are outside the system at the time. The providers you will hear from are primarily management and administration. What kind of mechanism have we as a group and you as a committee tried using to gain information from homemakers, who are the cornerstone of the MSA system?

Paul asked before, how do we get input? Has there been an opportunity to get lists of people who are users of service and invite them here? Those of us who get information about these committees are part of organizations. People who use service and care givers who supply that service do not have access to this information. Maybe these meetings should be out in the community in a church hall rather than here at the Legislature. Maybe then we would get some users of service.

I have been criticized for talking negatively about consumers as opposed to users of service. Let me assure you that I think it's important for consumers to be here, and in fact I could support every single point that the Ontario Coalition for Senior Citizens' Organizations has made; many of them are my own concerns. They need to have more reflection than just having been read at this committee, because when I look down again at the list who are presenting to you today, you will have a very biased perspective: all providers.

There is a difference between the consumer of long-term care and short-term care. Many people use acute care services or long-term care services for a finite amount of time. Yes, they're users of the service, but the users of service you want are the people who are in this for the long run, who aren't going to get out of surgery and feel better next week.

The system is in place because of the needs of the client; the client is not there because of the needs of the system. Please keep that in mind when people come, and think of the poem. Will that person get their needs met?

I'm always one for feedback. I see nothing about feedback. I feel there should be an independent evaluation of what is happening in community services. What is the MSA doing? Unless we have an independent way to evaluate ongoing services by all people who go into these homes, we will never know what is happening.

Appeals: I congratulate the government again for including this in its first draft. It needs fleshing out. The appeals primarily are from the service provider's perspective. To me, it is bafflegab. I don't understand them. I just give you one example: I am a user of service. I want to have a bath more than once a week. The agency has told me they cannot afford this. Can I appeal that? Will I feel greedy if I appeal when there may be other people who need to get out of bed in the morning and need help for that or have serious medical problems in their homes? Will I feel greedy? But just think for a minute, ladies and gentlemen, would you feel grungy and smelly if you didn't have a bath for seven days? Do these users of service not have the same rights as you to be clean? Let's not pretend if we're going to have an appeal process.

Regarding program supervisors: You all know I was here with Bill 101 and I have always had concerns about how residential services branch monitors its long-term care facilities. Not well enough, I can say. It's not good enough for compliance advisers to go to facilities, we have learned, and sit in the nursing station and read the charts and look at the record books. To really know what is happening, you want to speak to the residents, speak to the families, see what's happening at meal time. Are residents being fed or is the food going into the garbage? Charts can't tell you this. I'd like to say to you that this is not different from what will happen in people's homes.

Sure, there's lots in this legislation about program supervisors going to community agencies and reading the charts and looking at the record books. What does that really tell them about personhood, about the person in the poem whose knees were locked and could barely stand up again? Charts don't tell you that. How will we know if program supervisors are not in these homes?

Of course, my last point indicated is about orientation. I find so often that users of service, whether they're seniors, the physically disabled, aged patients or families that have children, who are all included under this legislation, don't really know what their rights are. Someone mentioned about the bill of rights. This bill of rights should be included in the handbook and in fact explain to people what does it mean, what are the rights under the bill of rights.

But let me say to you, there has been a bill of rights under the Nursing Homes Act since 1987. Not that I want people to have to go to court about their rights, but there's never been a prosecution under the bill of rights. I'd like this group to figure out in some way how the bill of rights can be used effectively.

Within your package, I have indicated what questions I think should be used for a feedback form for consumers; I would just like to read a couple of them out loud. Have any community services gone around, and some of them do -- and I want to tell you, I may sound critical, but I have a very high respect for the community social services that are providing services in our homes and communities today, but I worry that with the event we have more complex care, more frail elderly, many more people living alone, will the services be able to meet their needs? They aren't at the present time, by the way, and I concur as well with OCSCO, who spoke about the funds and where this government's values really are. I know they're strapped for funds, and I do appreciate it, but I'm an advocate for seniors, so that's where I think the money should go.


Anyway, a couple of questions for consumers: Are you satisfied with the quality of service provided by your homemaker, respite worker, home helper, nurse, physio or OT? If not, what would make it better for you? Do you receive all the services you feel you should receive? If not, what is it that you need and how often? Have you ever felt intimidated by the person providing you with help? Have you complained? If yes, what happened? If not, why? I've given you 19 opportunities and questions there. Again, I see very little about feedback.

The Advocacy Centre for the Elderly has just written a newsletter indicating problems with abuse. I can assure you that abuse is closeted and the 4% that we hear of seniors being abused is the tip of the iceberg. With more people on the agenda, I fear for the abuse of seniors in their homes.

As I said at the very beginning, you will have many providers coming. What are you going to ask them? I know the regulations are important. I know the statute is important. I'm worried about the users.

Maybe questions to them should be: As a service provider, are you willing to give up control and accept the client's decisions and choices? Many do. Many will have more difficulty with that when they have more clients and less time. If you are a service provider, given environmental, fiscal, political and structural realities, can client-driven services be implemented where you work? Are client choices and decision-making supported? Always, sometimes, never, or it depends? Depends on what?

What do we mean by managed care? Is it the resources we are managing and protecting from the client?

I close with another poem. This is called Solitary. This was written for a nursing home resident, so those people who may come from facilities to tell you how lonely people are in their homes, it's the same whether you are in a facility or whether you are in your home. It also indicates, where the legislation does not indicate, the importance of volunteers in our system. It's called Solitary.

She sits here waiting patiently

And wipes away a tear

Wishing that a visitor would

Suddenly appear.

Someone to say "How are you?"

And greet her with a smile;

Someone to sit beside her

And chat a little while.

It's hard for her to understand

Just what she's doing here;

What's happened to her family

And friends who were so dear?

How come she's been abandoned

Like some worn-out shoe;

What crime has she committed,

What bad thing did she do?

Tho' she has a bed to sleep in

And she's sheltered from the rain,

There's precious little else

Except her loneliness and pain.

She's only one of many

At home alone today

Who finds the price for longer life

Much too high to pay.

That picture could be changed

If all of us would spend

Some extra time just visiting

A relative or friend

Who's shut away from all

That once was held so dear

And needs to be reminded

That friends and service are near.

To take her by the hand and say,

"How are you?" with a smile

And then sit close beside her

And just love her for a while

Is that too much for her to ask,

Too much for you to pay?

Many need a friend and service

Will 173 help or betray?

Again, I am very pleased that Bill 173 is on the floor, even though I have suggested some changes. I thank you for your attention.

The Chair: Thank you, in particular for your questions and your poetry. We'll start the questioning.

Mr Jim Wilson: Thank you, Ms Goldstein, for once again bringing forward I think some very good points, particularly with respect to the bill of rights. If you don't mind, I just thought I'd ask Mr Wessenger what the enforcement mechanisms are in the bill of rights. It's my understanding in the reading of this legislation that a service provider is deemed to have entered into a contract to respect and uphold the bill of rights. That service provider may on occasion be the minister herself, or an approved agency or others. What if somebody violates or fails to uphold the bill of rights? What penalties occur?

Mr Wessenger: Mr Wilson, I'll ask legal counsel to answer that question.

Ms Czukar: The consumer has the ability to attempt to enforce it privately. That's what the deemed contract is about, and we've been told by people that that option needs to be there even though it's recognized that many users aren't able to use that very effectively without some support from advocates or others.

Mr Jim Wilson: Legal counsel.

Mr Jackson: Legal aid.

Ms Czukar: Legal aid, legal clinics.

Mr Jim Wilson: You're into contractual law here, aren't you?

Ms Czukar: Legal clinics would normally help out with that sort of thing in the case of vulnerable people. The other means of enforcing it of course is that where a service provider is an approved agency, which would be the case in most cases, the minister can withhold funding and can revoke an approval where the provider, the approved agency, is in breach of the act. That's the main mechanism for accountability and ensuring that agencies do respect the rights in the bill of rights. It's really a statement of expectations to users about what they can expect from the service provider and to service providers about what the government expects them to do if they're going to continue to receive funding and be approved under the act.

Mr Jim Wilson: Thank you.

The Chair: Did you want to comment on that, Ms Goldstein?

Ms Goldstein: I appreciate the comments that you've made. I do still have concerns about it, because I have watched it for seven years under the Nursing Homes Act and, quite frankly, I haven't seen that it's been very effective. I certainly appreciate the vision, the importance and all of the things that are listed there, but I am not sure that the people who work in the facilities take the bill of rights seriously and apply it at all.

Mr Jim Wilson: I was just wondering along this line, because it's a very good point, would it not be simpler to set up a mechanism that's more user-friendly for, as Ms Goldstein says, the user of services? Okay, you've got breach of contract, so somebody could take private action; why not some sort of -- we all understand fines, we all understand that system, where it would be a provincial offence or otherwise for breaching the bill of rights. Can you give us just the legalese around that scenario?

Mr Wessenger: Thank you, Mr Wilson. I wasn't going to give the legal but I was just going to make a comment with respect to this --

Mr Jim Wilson: Suing the minister is a little difficult.

Mr Wessenger: If I could make a comment on Ms Goldstein's concern about how we enforce these, I think we have to remember we can't look at legislation in isolation from other legislation. I think of some prior legislation that has been passed by this government that hasn't been brought into effect yet, that is, the Advocacy Act, which will certainly, hopefully, provide a mechanism for giving greater protection for vulnerable people who are either in facilities or receiving services in the community. That hopefully will be an added protection and to ensure that the bill of rights is more effectively --

Mr Jim Wilson: But, Mr Wessenger, that's very nice, but all the advocate can do is advise the client or the user of service that they have a right to take private action if there's a breach of contract, or maybe could help them inform the minister so she would stop funding to a particular agency, but you've got to remember that it's kind of strange; the minister also could be acting as a service provider. How does the average user of service easily strike back at somebody who violates their right?

Mr Wessenger: I think that's true with anybody's rights in society. Everybody has rights and you have to have a mechanism for assisting people to exercise those rights, and that sort of depends on what support systems are in effect. If you don't have any support systems, if you don't have any legal clinics, if you don't have any advocacy services, if you don't have any alternative community workers to assist -- you have such organizations. For instance, I believe there's a seniors' advocacy clinic, if I remember correctly, a legal clinic. So there are some mechanisms out there and the reality is that rights depend on the support system you have in to assist in the enforcement of those rights.


Ms Goldstein: If I could just say something here, I think the reality is based on fear: users' fear and the government's fear of the industry. I don't know what will happen with community services because I know what their philosophy is based on, and they always try to serve needs. I do know what's happened with the facilities, and I do believe that your discussion of fines is excellent.

When I was on the board of Concerned Friends of Ontario Citizens in Care Facilities, I can tell you that for years we discussed having fines for people who were in noncompliance of the act. We were told at one time that was going to be in the legislation, and it never got in the legislation. There are no fines for anyone, and facilities just carry on providing not good care without any sanctions. There is no reason why they shouldn't continue providing not good care. So we have discussed the issue of fines when it's come to facilities. I hope there won't be a need to in this case, but I think they should be there to back it up, because my feeling is we won't be looking at this legislation for a really long time and I'd like it to be done right a little bit this time.

Mr Malkowski: Thank you for your presentation. It's very comprehensive and very helpful to those of us here on the committee. You've raised some very good points and concerns, and we hear your words; they're important to us. I also would like to congratulate you on your teamwork in your presentation, on the first MSA, on the work that you've done with the minister. I want to congratulate you on the work that you've done in the past.

I come from the riding of York East. We've been very active. We have very active service providers and consumer groups, and the DHC has been working very, very hard with the local community groups. It's very exciting to see how things have evolved.

I'm wondering if you could tell us a little bit about the local DHCs, leading and planning, which way you think they should go. Could you tell us a little bit about that?

Ms Goldstein: Thanks for putting me on the spot. I suppose I'd see myself in a bit of a conflict of interest here. But what I can say about the local DHC is that I'd really like there to be more resources for the district health council in Metro Toronto to be able to involve front-line workers, consumers, care givers, volunteers, and any community agency that would like to be involved at the DHC level to do their planning.

The problem is resources and the number of people I understand are at the district health council. I've worked very hard in that process but I also recognize that a lot of people feel their views and their input have been left out. If there would be any way that we can incorporate more people to be involved in the process, it would please me.

Mr Malkowski: Thank you very much for all your efforts and your volunteer work, the time. It's been very challenging, I know, and we look forward to working with you in the future and thank you for your feedback.

Ms Goldstein: Thank you, and I continue to work hard.


The Chair: I call our final witness for this morning, representatives from Senior Link. Welcome to the committee, and would you be good enough just to introduce yourselves for the committee.

Mrs Judith Leon: I'm Judith Leon, the executive director of Senior Link, and Marilyn Pratt is director of planning and research.

Mr Chairman, it's a bit hard for me to come and talk to you as a manager of one of those iniquitous agencies that Ms Goldstein just spoke of. I'm a bit surprised by what she had to say because for years she has brought her students from Ryerson to Senior Link every year and talked to them extensively about how marvellous Senior Link's client-driven services were. Perhaps afterwards she'll tell me what on earth we've done wrong that she would suddenly apostrophize us as being money-grubbing people looking out for our own self-interest.

Senior Link is a neighbourhood agency which was started very much entirely by consumers or users of service who were not getting the service they needed from the big, established agencies like home care and the big services in Metropolitan Toronto. It was started by a group of local seniors.

I happen, by background, not to be a nurse, not to be a doctor or social worker. I'm a prehistoric archaeologist by training, but I also was a political flack in Britain many long years ago and I was asked to become involved with the agency because they needed access to money and help. And because of my particular background, I tended to know how to access you gentlemen and ladies around this table, which enabled us to provide an alternative to the established services then available 15 years ago in Metropolitan Toronto, where one saw case after case of seniors dying in their own homes from lack of help because they were unable emotionally or physically to ask for help or, when neighbours asked for it, the people did not conform with some rule or another.

I don't wish necessarily to criticize home care per se. They have rules which they were bound to by the governments who set up their terms of reference. But be it as it may, most services in this city now, or in this province now, are geared to certain services. They're not geared to the needs of the individual senior who approaches them. They're certainly not geared to the many, many seniors who need help but do not know how to approach them.

This bill that you have before you now is the government's recognition, I believe, that services to seniors not only are fragmented but, much more importantly, are wrongly focused. It has been a long time now that there has been ample research that homemaking and personal care -- which is what home care does -- and some of the nursing services, though good in themselves, do not decrease institutionalization. This is contrary to what many people say, but the research in Europe is very clear. You can increase the amount of homemaking going into an individual person's house by manyfold and it will still not decrease the level of institutionalization.

What the Europeans have found and what I think was the aim of the government when it first began to work on Bill 173, though it's gotten lost in the process, is that what you need is, if you want to be formal, a case manager -- if you want to be informal, as Senior Link does, a community worker -- who can go into that house and act, if you like, as a surrogate son or daughter to the person who needs help. I don't mean that they are a son or daughter in personal terms, but in the sense of the things you would do for your mother or father if they were alone and in need of help: the finding of a workman to fix a roof, the sorting out of a row with a neighbour over a tree that's fallen down, anything like that which is going to help the senior function within their own home, as well as the more obvious basic needs of homemaking and crisis intervention.

The research has also shown that small agencies deliver services in a far more client-focused -- or consumer-focused, as we now call people; the words change, whatever is current at the moment -- way. When a staff person of Senior Link goes into the home, their object is to find out what the senior wants and, if possible, deliver it, whether it's a paid service that they can arrange or an unpaid service for which they have to find a volunteer.

I think that's what the government wants when it has introduced Bill 173. Unfortunately, the people who drafted the bill, I think, or the way in which the bill was written, it's really a rewrite of a previous government acts. It doesn't reflect on the new ways which have been developed of helping people. It's not authorizing neighbourhood multiservice agencies to deliver all appropriate services at the seniors' and their own best capabilities and it's not authorizing envelope budgets.

What should be happening, we feel, is that the agencies which are responsible, these new MSAs, multiservice agencies, should be told: "You go and do anything that you possibly can that the senior needs help with, whether you do it through a paid source or a volunteer source, and you use an omnibus budget. We're not going to tell you you have to have two hours of homemaking and one hour of personal care and three hours of transport and two hours of meals, or whatever it is, in a rigorous, set form for which there are a kazillion rules. We're going to tell you to provide that service as best you're able with the money and volunteers you have and then we will send in top-of-the-line operational auditors."


They do not exist in Ontario at the moment, but it's not hard to set them up. Those operational auditors can then determine that the agency, the MSA, is doing its job properly by visiting every 87th name on the database of seniors or by going out and checking a street on their own to make sure that all the seniors who need help are actually getting it.

There have been two objections to what I have to say. One is that the services have to be the same throughout the province, and that if one agency does something differently from the other, this will be wrong. I think that's nonsense. Obviously, seniors should be able to get services anywhere in the province, but different areas of this province have vastly different needs in terms of what the seniors who live in those areas want.

The second objection to the matter of envelope budgeting is that much of the money that Ontario uses in fact comes from federal-provincial cost-sharing and that the feds require that one statisticize how much service is being given for their money. There's no reason, however, why MSAs that keep statistics till they're coming out of their faces can't keep the appropriate stats. There's also no reason why Ontario cannot go to Mr Axworthy's review of the social services and say, "We want to change the ways in which we account to you for federal dollars."

Senior Link therefore recommends that MSAs, as a global program, be empowered to deliver appropriate services with a global budget and that their effectiveness be ensured through the use of detailed, personal operational audits.

Comprehensive service is one of the buzzwords that everyone uses, but in this act you have long lists of things which are going to be included. There are equally long lists, ladies and gentlemen, of things that ought to be in that act -- and some of the people who were speaking earlier this morning mentioned them; supportive housing was one of them -- but which are not. So really the act is predetermining what the MSAs should be delivering, and I think this is very regrettable.

As I mentioned earlier, a lot of research has shown that what people really need is that one person who goes in and helps a senior as they're beginning to need help. Initially, it might just be organizing somebody to mow their lawn or do their shopping in the middle of winter because of the ice on the street, nothing very much. But that same person, not somebody different every time like happens with all these big agencies, being responsible as the senior or the other people who come within the tenet of this act need help.

It's not somebody who's going to say, "Well, it's not my job to do that" when they come into a house and discover that somebody's had diarrhoea and there's a mess scattered around the floor. It's not somebody who's going to say, "Well, I'm sorry you're being evicted from your apartment, but you'll have to go to legal aid or something because that's not my job," because most seniors, when they become so frail that they need the kind of help that agencies like we give them, are not emotionally able to go and find the people who should be helping them. Those people may be there, but they aren't emotionally able to access them.

It needs a community worker or a "case manager" to go out and find the public service lawyers or whomever it's going to take, find the owner of that apartment building, cajole him to change his mind, promise to help the senior clean up if the senior's being evicted because the apartment is filthy, whatever it takes.

That kind of community worker is the most important part of keeping a senior in their own home, and by whatever name you call them, community worker, case manager, client intervention worker, they are not mentioned in this bill at all. If we must have the system of listing things which have to go into the bill, then if I may, I would like to recommend the inclusion of client intervention and assistance within the bill.

A few minutes ago, I was talking about problems the senior might have in their home with, say, a neighbour or a problem with a tree or work orders on a house where public health or somebody has put work orders on a person's house. One of the things this client intervention worker would be doing is fighting with whatever authority is trying untowardly to intervene, to help the senior. Quite often, for example, public works or the public health inspector, and I don't mean public health nurses, will try to turn a senior out of a very dirty house because, "It's for their own good to live in a nice, clean nursing home."

You may wonder why I'm a bit belated speaking of this when it should have been in front of you for the Advocacy Act, but the point is, formal advocacy is all very well that you've set up in your advocacy acts. What it doesn't include, and what is more common, is the informal advocacy where a client intervention worker will try to sort things out before they get too bad. That happens in my agency. Maybe six or seven times a week we deal with that kind of informal advocacy. It's very cheap, it's very cost-effective and then the senior doesn't have to have strangers coming into their home to be formal and rather scary advocates. So we recommend the inclusion of informal advocacy in the list of services that should be provided.

One of the most serious omissions in this bill, to me, is its failure to obligate the MSAs to search out the people who fall between the cracks. Technically, this bill is setting up yet another of the long stream of vertically integrated organizations; that is, organizations which are judged by how well or badly they serve the people whom they have accepted as clients.

Senior Link has always believed, and a lot of modern research confirms this, that horizontal integration is the only measure of real value. That is a technical term meaning, how many of the people out there who need help are getting it, and then what is the calibre of the help? It's all very good for organizations to go around saying, "We provide 95% of the help for people we've accepted as our clients," when out there there are people living in untold misery in their homes who aren't able to access the system. It's not that the system won't help them if they do access it. They don't know how to access it; they're not able to.

It's no good putting little letters in pension forms, because 60% of seniors are functionally illiterate and cannot read those pension forms. You have to go and knock on the door, year in and year out, and that's what MSAs should be required to do. It's done entirely by volunteers. It doesn't cost anything. It's not a dollar issue. You simply say to all three local political parties: "Look, guys, we're doing a canvass in May. If the Tories are giving us 25 people to canvass for us, will the NDP give us 30?" You get those people to come and help. It works very well. It finds the people who slip through the cracks.

I think you have to put something in this bill and we would recommend that MSAs be mandated to provide horizontally integrated services.

We think also that there is a problem with saying that there are four years for transition and then everything shall be part of the MSA. In terms of services like homemaking, I think this is quite legitimate. Homemaking is primarily housecleaning and personal care. All local agencies do that anyway. That's readily done within a local community.

In terms of the nursing services, this is slightly iffy. The basic nursing services should work out of the MSA as a part of the MSA on secondment from one of the big nursing agencies, but I think the specialist nursing services, the IV stuff, that kind of specialist nursing service, is best left in a big regional body like the VON or Saint Elizabeth nurses, where one contracts for those special services to the MSA when one needs them at a predetermined and reasonable cost to the MSA.


What we're recommending is that, instead of saying those services will be enfolded into the MSA at the end of four years, at the end of, say, two operational years you review the service and see how it's working as a secondment model, and if it's not working well, then by all means push it into the MSA, but if it's working well, then reconsider it.

I should say we have no nursing contacts whatsoever. I'm not doing this as a member of any nursing body of any kind, shape or form. It's purely that as a community agency we think this would work quite well.

My final point, and it's just a point for you to think of, is I think your appeals procedure is quite unworkable. By allowing anyone to appeal at any time, you're not only getting the people Dian spoke of who certainly need to get around at the agency and do an appeal quite genuinely, but you're also getting all the manic-depressives and people of that nature who make a habit and a lifestyle out of complaining and appealing five times a week. If you have a procedure which automatically accepts anyone who's complaining to go to an appeal, your appeals will get totally bogged down.

We're just suggesting that you might like to require that people go through a procedure with a local MSA, with the supervisor or the executive director or the board of the local MSA, before they appeal to a provincial body, simply for convenience sake.

Ms Carter: I can see why Dian Goldstein smiled when you said you were one of these terrible providers, because you're obviously nothing of the kind, you're very consumer-oriented and dedicated. What you've been doing is to give us some policy suggestions. Obviously, this act is not cast in stone. It will be amended and I think some of the things you've been saying may be grounds for possible amendments.

In that vein, I wonder if you could tell us: Supposing it just happened that in the way things panned out in your community, Senior Link were the MSA, how would the kind of drive and consumer-oriented focus that you have be carried through and transferred to the whole area of the MSA?

Mrs Leon: One of the problems, Ms Carter, is that we still don't know and have not got any statistics of how many people would likely be part of an MSA, given any predetermined size. My best guess is that if East Toronto were to have two MSAs, one in Riverdale and one in the Beaches, which is my area, my agency, which has a present budget of $7 million and a staff of about 40, would have a staff of maybe 400. That's a guess.

If Senior Link were the MSA, we would be adding to our ranks a great many home care workers and nurses. The nurses we work with very closely already, so that would be no big problem. Home care workers would -- and many of them are very able people, but if they were part of a Senior Link MSA, they would have to learn a great deal more of taking responsibility for themselves, because we tend to believe it's the person working with the senior who should make the decisions, once properly trained, which doesn't happen in these big, huge organizations. They would have to learn that it's what the senior wanted that happened rather than what the rules say. Senior Link doesn't pay a whole lot of attention to rules, I'm afraid.

The big problem, though, at the moment is that in Metropolitan Toronto the district health council, for its own reasons, and far be it for me to say what they are, has decided that MSAs will be big, huge organizations. At the moment it's going to require major, major advocacy for Senior Link, or an organization of Senior Link's size, to remain. The theory is that we get closed down and a couple of neighbouring agencies get closed down and then some huge amalgam takes our place. It won't work, in fact, because only about 20% of our funding comes from MSA dollars. So in fact, if that were to happen, that scenario, we'd have far more fractured seniors' services than we have now.

Ms Carter: We have been told by various presenters that we would lose the volunteer component under the provisions of the act because somehow people wouldn't want to work for big government bureaucracies. They want to work for specific agencies or specific groups of consumers. We certainly don't want that to happen and we see the volunteer component as a very necessary and ongoing one. So what can we do to make sure that prophecy doesn't come true? Surely, the answer is that the community has to be involved. It seems to me it is involved and it's going to continue to be involved. How can we make sure we keep the volunteers?

Mrs Leon: Ms Carter, Senior Link has I think about 25,000 hours a year of volunteer service; a lot for a small, local organization. If a new MSA were to be an organization of the size of Senior Link, which is roughly a city ward, give or take a bit, then I don't think you have any problems with your volunteers. But if what's happening in Metro Toronto's DHC is the norm throughout Ontario, which I gather it is, the powers that be are deciding -- not your government but the people who are implementing the government's decision -- these MSAs are going to be huge, and no, you wouldn't get any volunteers working with them.

Mr Dalton McGuinty (Ottawa South): Thank you for your presentation. I just want to follow up on the distinct possibility, and I guess it's a probability, that we're going to be dealing with large MSAs in the future. What is going to happen to your employees?

Mrs Leon: If the MSA is not Senior Link, most of them will be unemployed, I suspect. The reason for this is because if there are these huge organizations, then everyone who works within the system will be entitled, obviously, to apply for a job within the new organization, along with hospital workers and a whole bunch of other people. But what's going to happen with those huge organizations, I can absolutely guarantee, is that the people who run them are going to be the existent, fairly powerful bureaucrats in Metropolitan Toronto in the various systems that you're closing down, and without exception, those people do not interview and hire on the grounds of, does this person who's going to be a community worker or -- well, they won't be community workers under that system, but does this person understand seniors, do they care about seniors, are they good advocates? They're going to be interviewed on: "What are your academic qualifications? Do you have a master of social work degree? Are you a nurse?" If not, you go right to the bottom of the list. Senior Link, I'm afraid, has always chosen to hire on -- we have people with very high academic qualifications and we have people who were former waitresses in restaurants.

I should tell you that by no means do high academic qualifications make good people working with seniors. I personally am awful when I go into a seniors' house. I just do not have the particular skills of knowing, does this person want to be touched, does this person want me to keep two feet or three feet distance, how much does this person want? I happen to be more of -- an organizer, if you like. But you have to hire the people who instinctively know how to deal with other human beings and it doesn't matter a tuppeny damn whether they've got degrees or not. You can teach them what they need to know, and you certainly have to teach them -- I'm not suggesting one sends untrained people out for one minute -- but they can be taught internally or at a few good courses. Humber runs superb courses in community work and some of the others do too. But those aren't going to be the people who get hired.

Mr McGuinty: If the alternative is between the status quo and larger MSAs of the kind which you've just described, which is your preferred alternative?

Mrs Leon: I would dearly like the system reformed, but if the reform is going to mean large MSAs, I'd prefer to stay the way I am because now I can play off home care against the VON, against Saint Elizabeth, and somehow or another, I'll find somebody to come and provide the professional help which my staff aren't capable of and do not wish to be capable of doing.


Mr Jackson: Judith, good to see you again, welcome. At that pause, when you were about to describe the type of person you are, you're more of a powerhouse than an organizer. I recall when you impelled me to come and visit your facility and spend half a day with you, and Mr Wilson as well, several years ago.

Mrs Leon: You're welcome again.

Mr Jackson: It was an eye-opener in the extreme, and I couldn't help but be struck by, every time a need appeared during your evolution, you found the resources and, more importantly, the human resources to respond to that need. Therefore, there's almost an analogy that you could be defined as the perfect MSA because you already are one-stop shopping and you provide a basket of services.

For those members who are unfamiliar with Senior Link, you provide housing, you provide every range of support and if you don't, you will go and find that. In many respects, you're what's good about the system we have currently but being cast as what is requiring reforming and tinkering with. I want to thank you, first of all, for putting that in perspective for the thousands of seniors you serve, and maybe you could remind me of the actual ward in Toronto that you --

Mrs Leon: It used to be ward 9. It's now a mixture of 10 and 9.

Mr Jackson: I certainly think if the residents of that community were able to speak before the committee, they would indicate many of the elements of the one-stop access and responding to the needs with the kinds of caring professionals.

The themes that you've raised in your presentation were presented yesterday as well by Catholic agencies in Toronto, and they were talking about their ethos and their mission statement. This really had very little to do with being Catholic; it had everything to do with their approach. I think there was some confusion on the part of some members, but quite frankly you have that same ethos and that same mission statement and purpose which you bring to your organization.

How are the current discussions affecting you in your specific area with respect to your relationship within the MSA? Have you had any indications what role you may be called upon to play or whether the grand plan is to phase you out or if the grand plan is to attempt to integrate your capital assets but not necessarily all your programs? I'm convinced that under the MSA there'll be less breadth of service. You talk about horizontal integration in your report, and therefore I can see, almost, your organization being cherry-picked for its best elements and the rest abandoned.

Mrs Leon: Cam, you were kind enough to refer to Senior Link as a typical model of what an MSA should be, and in fact I would say that when Frances Lankin was the Minister of Health -- she happens to be our constituency MPP and she did in fact base her initial thoughts, and makes no secret of the fact, on what she knew of Senior Link, which was extensive and detailed. She's been a very loyal constituency MPP to us. But somehow during the development of the MSA process, as it got out of the politicians' hands and into the hands of the developers of the process, something went skewed and it went back to versions of the old system.

In terms of what would happen to Senior Link, if we were to win the battle which we are currently fighting, then we would be the MSA with the extension of the home care workers and people of that nature. However, the district health council, I understand, is very vocal in saying that we will not win this battle and that there will be one huge MSA for east Toronto. They are totally ignoring the fact that both the neighbourhood agencies, which are ourselves and WoodGreen Community Centre, own 80% of -- none of our capital goes nor legally can they take it. I have checked that with very high-powered lawyers. It's ours. The United Way and Metro community services have both made it clear that their moneys will continue to go to the two community agencies if we stay in existence, and we'll lose 20%, or 25% in WoodGreen's case, of our money to an MSA which will be out there.

This will devastate both of our agencies because it's impossible to provide supportive housing. Senior Link has about 350 units of supportive housing. We cannot provide it if we don't have the community workers to integrate with the housing people to provide that service. What we would do would be to turn Senior Link into a housing and advocacy agency and advocate against the problems that the new MSA almost certainly would have.

The Chair: Thank you. I'm sorry there isn't further time. We should probably also underline that this is a unique presentation in that I doubt we have had before a presentation by a prehistoric archeologist, nor are we likely to have one subsequently in our hearings. We thank you both for coming this morning.

The committee stands adjourned until 2 o'clock.

The committee recessed from 1216 to 1408.


The Vice-Chair (Mr Ron Eddy): Welcome, ladies and gentlemen. We're a little late getting started. The first presentation is by representatives of the Social Planning Council of Metropolitan Toronto. Would the representatives come forward and proceed with your presentation. We hope there's time for questions.

Mr Peter Clutterbuck: I'm Peter Clutterbuck, with the Social Planning Council of Metropolitan Toronto. Mr Chairman, members of the committee and ministry officials, I appreciate this opportunity to talk to you today on Bill 173, An Act respecting Long-Term Care. I've distributed copies of the brief with some appended material.

I was hoping to be sharing this presentation with several of my colleagues from social planning councils in the greater Toronto area. Unfortunately, timing and last-minute family business have not made this possible. This presentation, then, is officially being made on behalf of the Social Planning Council of Metropolitan Toronto, which is an independent community agency in the voluntary sector dedicated to social research and policy analysis on issues relevant to the social wellbeing of Metro Toronto's residents.

I did, however, in preparing this presentation draw from the deliberations over the last year of the Social Planning Network of Ontario on the integration of health and social services in the province. The Social Planning Network of Ontario is made up of more than 40 community-driven social planning organizations across the province, including the Metro Toronto SPC. I also did have a chance to talk about my message here with Paula DeCoito, the Peel Social Planning Council executive director, who unfortunately had to cancel her appearance here today.

Long-term care reform in Ontario has been a project of the last three provincial governments since the early 1980s. The Conservative government's minister for senior citizens' affairs proposed A New Agenda in 1986, followed by the Liberal administration's Strategies for Change in 1988-89, and finally the current government's Redirection of Long-Term Care and Support Services in Ontario in 1991. Each administration and many ministers with a variety of associated responsibilities for the reform project have tackled the complex web of issues involved. Some community groups have expressed much frustration at the lack of action to date. They may well be pleased at the fact that there is finally a bill on community services integration before the Legislature. That does mark progress in one way, but it is as important to understand fully the implications of what may be done in Bill 173 as it is to proceed with some form of action on long-term care reform.

The Social Planning Council of Metropolitan Toronto has maintained an interest in this latest reform since the Strategies for Change consultation process. A community forum attracting more than 200 participants in January 1991 led to the formation of a long-term care community coalition of concerned individuals and agencies which the SPC convenes regularly for review and discussion of reform developments. The long-term care coalition has made representations to the relevant ministers and ministry officials on issues which have emerged since the Redirection paper was released.

Most recently, the Metro SPC has prepared and released to its membership and the larger community a Social Infopac which summarizes and offers commentary on Bill 173. This has been appended to the brief which was distributed to the honourable members, and I ask you to consider some of the issues that are discussed in the infopac. I'll not repeat the specifics raised in the infopac, but wish here to highlight several overriding issues of concern with respect to Bill 173. They are the integration of health and social services, the dominance of the health model, and the dilemma of policy prescription versus policy avoidance.

First, on health and social services integration: From the government's perspective, the objective of long-term care reform has been to organize and manage an integrated system of health and social service delivery for seniors and physically disabled people in Ontario. There has been strong community demand for a better-coordinated system of community and institutional supports. There has also been growing concern about the social and economic costs of early institutionalization versus supporting people in their homes and communities. Long-term care reform has also been touted as a forerunner or prototype for more comprehensive integrated service approaches for other populations.

Bill 173 makes some useful strides towards the concept of integrated community services. Subsections 2(2) through (7) of part II describe four types of community services which fairly comprehensively range from basic daily living supports -- community support services and homemaking services -- to more extraordinary and specialized assistance -- personal support services and professional services. The range of services listed gives some sense of both the distinctiveness and the complementarity of health services and social supports within one system.

The plan for service described in part VII is one integrative mechanism which may provide a degree of individualization for people needing support. The overall force, however, of the references to the plan for service throughout the bill suggests a relatively passive and reactive role for the service consumer. There is an assurance of consumer protection under section 3 in the bill of rights, but it really cannot be so confidently made when persons needing service are dependent on the resources of the approved agencies, which they are expected to challenge as service shortfalls occur.

The primary integrative structure in Bill 173 is of course the multiservice agency described in part VI. Designated by the minister, MSAs will have both direct service and purchase of service powers. There is not much further development of the MSA model within the main body of Bill 173. The structural and operational dimensions of the MSA model were much simplified by firmly incorporating it and its community services integration functions within the Ministry of Health, and this, in our point of view, is the main problem. There is real hope here for a strongly integrated approach conceptually in the bill, at least in outline form. The main problem is how that is going to be administered or actually carried out.

Health model dominance: The long-term care reform of Bill 173 is clearly driven and controlled through the Ministry of Health. Early in the life of this government, long-term care reform, or redirection, was a triministerial initiative with the lead responsibility resting with the Minister of Community and Social Services. Although the ministries of Community and Social Services and of Citizenship remained identified in the policy documents released in 1993, Bill 173 finally sheds both and institutionalizes responsibility for integrated community health and social services in the Ministry of Health. This is explicit not only in the act under consideration, part V, but also in the proposed amendments to relevant acts which transfer authority for homes for the aged from the Minister of Community and Social Services to the Minister of Health.

The bill's proposed amendments to the functions of district health councils in part XII, in conjunction with the Health minister's powers of delegation of ministerial authority in part XI, also make it clear that district health councils will act for the minister on the implementation of an integrated community services system. In fact, district health councils in Ontario have exercised this mandate for more than a year now with respect to long-term care planning. The amendments to the Ministry of Health Act on the functions of DHCs also prepare the ground for a larger role in future human services integration initiatives out of the Health ministry.

The members of the Social Planning Network of Ontario are concerned that the long-term care implementation process reflects primarily a top-down, highly centralized, professionally driven corporate planning strategy. Community involvement has been limited to consultation rather than ongoing participation and decision-making. This approach risks producing an integrated service system for seniors and disabled people which is not accountable to community and which is unbalanced in terms of its health versus social support components. Social planning organizations are well situated to bring the community-based social support perspective to the planning process for an integrated health and social services system. Our role as planning partners, however, has not been recognized nor fully exploited.

The Metro Toronto SPC has joined with its more than 40 province-wide community planning partners in the voluntary sector to express strong concern to both the ministers of Health and of Community and Social Services that integrated health and social service planning in long-term care is being driven by the health model. There is a wealth of experience and community knowledge in social planning organizations across the province which has not been adequately supported by either ministry in the implementation of long-term care reform.

Local planning advisory committees have been organized, and in some cases social planning organizations have joined these discussions, but they have been invited to do so as stakeholders in the system rather than as planning partners, and they have been expected to participate in this major planning initiative without additional resource support. With the withdrawal of the Ministry of Community and Social Services from even a shared leadership role in the reform effort and the clear intent of Bill 173 to further empower district health councils, there is little likelihood that independent community planning bodies will have any meaningful role in the future development of an integrated system in this province.

This is a sadly missed opportunity. A truly balanced approach to integration would have involved joint policy leadership out of both ministries, definition of a shared mandate and allocation of adequate resources for health system planning and community support planning bodies to work effectively together.

While district health councils may recruit from the community and make every effort to reflect the composition of their communities, they remain professionally and institutionally dominated and, district health council members being appointed by the minister and serving at the minister's pleasure, their accountability is to the minister and not to the community.

Ironically, while institutionalizing centrally controlled planning in long-term care, Bill 173 actually reflects in other respects the very limitations of that approach, and that's why I'd like to conclude with the policy dilemma that's presented.

Bill 173 plots an inconsistent course between policy prescription and policy avoidance with the always fail-safe provision that almost anything can be done or undone at the minister's discretion anyway. Major policy decisions are hedged. For example, multiservice agencies will be designated for a geographic area which might be periodically altered at the minister's discretion, but there is also provision for multiple designations in or within one geographic area.

In addition, municipalities or boards of health will not be excluded from MSA designation but will only be considered after all other approved agency options have been considered. Section 12 mandates MSAs to "provide or ensure" community services in their designated areas but places a 20% budget limit on purchase of services in the four community services categories. This seems to be some kind of accommodation between the pure service brokerage and the direct service models that were talked about at one time.

Other issues which were once to be major parts of the policy framework are hidden or relegated to the regulations for determination. The issue of user fees for community support and homemaking services, a seriously contentious policy issue in early 1991, is buried in section 25 for determination in the regulations. Subsection 56(1) lists 41 areas for the Lieutenant Governor in Council to make regulations, a number of which are critically important policy issues, such as determination of funding arrangements, selection and composition of boards of directors of approved agencies, the addition of functions and duties to approved agencies. At one time in the development of long-term care these were the issues about which a limited number of options were being assessed for policy consideration. There is no treatment at all of an important policy area: support to family care givers.

What does this overreliance on regulations and ministerial discretion in Bill 173 suggest? We think essentially it suggests that the government has encountered a wide range of policy preferences in the community reflecting the real diversity which exists in long-term care reform across the province, and rather than explicitly testing a number of approaches with intentionally different features in order to inform the development and adoption of a flexible but coherent policy framework, the government has chosen to resolve its policy dilemma by avoidance through use of its regulatory powers and practically unlimited ministerial discretionary authority.


To conclude, it is difficult to make specific recommendations on Bill 173 addressing the issues presented above without fundamentally altering the very nature of the bill. Clearly, the social planning council feels that the joint ministerial approach initiated by this government should have been carried through to the legislation. Stronger support for active community participation and local planning processes should have been provided.

The one opportunity which seems to present itself is the fact that a comprehensive and definitive policy framework for community services integration is not resolved in Bill 173. Much is left to ministerial discretion and the regulations. This could allow the testing of a variety of integrated service delivery models which, over time, could inform the definition of a more coherent policy framework. This would best be an explicit and intentional provision of Bill 173, with a statutory review date five years or so down the road. Of course, any such initiatives should make provision for an effective working partnership at the policy level between the two principal ministries and, at the district and community level, between the health system and the community planning bodies, which both have strong networks throughout this province.

Mrs Sullivan: Thank you very much. At one point in your brief you have mentioned the issue of charges for services, and this issue was raised earlier today by the Ontario Coalition of Senior Citizens' Organizations. If I can just read to you what they say in their brief: "The distinction that is made between homemaking and community support services, where there is a fee, and between professional and personal support services, where there is no fee, is confusing. Seniors will need to prorate time and user fees, particularly if it is the same worker. This is complex and opens the door to the implementation of new user fees. OCSCO is strongly against any form of user fees."

You've mentioned the conundrum of fees for some services and no fees for other services. I wonder if you would comment further on the observation the seniors have made, that the new model, where there may well only be one person doing friendly visiting, Meals on Wheels or other personal support services, and where there are provided some of what used to be Comsoc services, perhaps right alongside some health services, and where there are different federal government transfers to the province, which I know you're familiar with -- how do you see this all shaking out?

Mr Clutterbuck: Whether we're talking about social services or health services in our community, the strong bias, in fact the push, is for more support at the preventive end of things: programs and supports which help people stay in the community, stay in their own homes and not have to use more specialized forms of care, and certainly to avoid institutionalization if at all possible.

It seems, then, a bit ironic that one of the areas in which we want to implement user fees is right at the basic, daily community living supports that people with these kinds of needs require. I'm sure the Ontario coalition of senior citizens knows very well the concerns of its members. Apart from being confusing for them in terms of what they pay for and who they pay for it -- and I think within the bill there is actually provision for these individuals being designated as collectors of fees, which we think is inappropriate -- apart from the confusion to individuals, if we're really serious about preventive and community health measures and programs which avoid institutionalization, we should be putting our heavier investment into these types of activities: supporting people's daily and community living needs when those are obvious and require that kind of support. So I would agree with the Ontario coalition of senior citizens in that regard.

Mrs Sullivan: I guess the concern is that the seniors themselves will have to be making some determination, or the client -- it may not be a senior -- will have to make some determination about what hours or what proportion of time is used for what services.

Mr Clutterbuck: Yes. There's another issue here. I think Evelyn Shapiro from Manitoba a few years ago -- I wasn't with the council then, but I believe she presented at a community forum. I know she presented at a community forum at the social planning council on long-term care reform in Manitoba, and I remember that one of her comments at the time was that the creation of a fee structure and differentiation for different types of services does lead to some need to administer it, some need to track it and some additional costs, which she wondered -- she didn't conclusively say -- in fact wouldn't have paid for itself if they just paid for all the direct services to people.

Mrs Sullivan: I'm interested in your comments about the integrated system and the predominance of health issues in this model. We've heard, I guess from York Home Care and from at least one other presenter already who have indicated that as part of their client base, 90% of their clients have an acute problem that has to be dealt with in association with some of the other support services that are being provided. As a consequence, if there is a health emphasis, it may well in fact be met through this model. Would you comment on that?

Mr Clutterbuck: I think one of the issues might be, you know, we all have a health interest. Health is an issue for all of us. I guess one of the real concerns is how much we have to rely on medical forms or more specialized forms of assistance for people, which tend to be more costly, and when appropriately given or made available to people certainly are appreciated and respond to very specific needs.

The real challenge I think in terms of supporting people in the community is to be able to more and more provide for more specialized and even medical needs to people who require them in their own homes and communities for as long as possible and to have to resort to the institutional placement as strictly a last resort.

There have been some experiments, in Vancouver, for example, and in places like San Francisco, where people who are fairly highly medically involved in terms of their needs do receive a fair level of support in their homes and communities, even with the transportation of special equipment sometimes to their homes for shorter periods of time so that over the longer term they don't have to reside in the nursing home or institution but might get periodically concentrated forms of specialized assistance that helps them deal with a crisis but also stay in their own home.

Mrs Sullivan: I think that's the one aspect this legislation contemplates that I favour in fact, that there would be home delivery of services when that was appropriate in terms of the treatment needs of the individual and where it's cost-effective and so on. Indeed in Ontario there are some very sophisticated treatments now being done in the home, not the least of which are chemotherapy and dialysis.

I'm not certain that therefore I can concur with your concerns about a health dominance when the evidence is that the first reason people are coming into the long-term care system is usually a health problem requiring a clinical treatment.

Mr Clutterbuck: That might well be the case in terms of why people might actually get it, but presumably there is some recognition of the fact that there is a need to bring together social supports and health supports in a more comprehensive system for people.

Mrs Sullivan: I don't think there's any question about that.

Mr Clutterbuck: And the real question, if we were strictly limiting -- you see, I don't think there's a particular advantage to strictly limiting health to medical services either. I think there is a lot to be said for the Health ministry's intentions, and expressed intentions, to try to develop a more community health orientation or a more proactive preventive approach.

The problem is that just assuming then that everything that is occurring in community services should be dumped into the Health ministry to actually be structured and run through the Health ministry denies a whole wealth of experience that exists at the community level, actually, across the province that could usefully be brought together for a more preventive approach. I say we're denying the strength of our social support systems in turning it over administratively strictly to Health.

Mrs Sullivan: Thanks. I appreciate that clarification.


Mr Jackson: Peter, I appreciate your brief, and especially the fact that you've given us in a very focused way a way of looking at this legislation in terms of its policy implications from an administrative point of view, and so I appreciate that.

But I'm rather shocked to hear from you that in fact there was no meaningful relationship between the social planning council here in Toronto or by extension elsewhere in the development process. Could you just briefly elaborate on that, or did I misinterpret what you said?

Mr Clutterbuck: I'd like to elaborate on that, because I also realize that it can be misconstrued in some ways. I realize that the district health councils were given a very clear mandate out of the Ministry of Health more than a year ago around their responsibilities in long-term care and that they have a job to do. We recognize that the district health councils at the council level and among their staff have real valuable expertise to offer the community, we think primarily around health system, health care and health institutional planning.

Unfortunately, the mandate that was given to the district health councils did not, as far as we can determine, make any specific provision for them to include that other important social planning resource in our community, social planning organizations in a variety of forms across the province, as partners.

Mr Jackson: I'm sorry to interrupt you, but I'm trying to get to the nub of this, which is, as soon as you realized that, did you contact the government and ask, "Why were we omitted?" Or did you talk to somebody officially in long-term care? Is it fair to say that you weren't involved in the planning process, and now I'm trying to ask at what point did you contact the government and what were you told?

Mr Clutterbuck: District health councils will say that there was involvement in terms of consultations and in terms of trying to bring people around the table. There's a difference between there being involvement as one of the other players and involvement in a partnership for planning.

I want to make that distinction, in terms of recognition of our mandate, in terms of provision of adequate resources to fulfil our mandate in the same way the district health councils were, and we have made these concerns very explicit to both the Minister of Community and Social Services and the Minister of Health. In fact, we've been more explicit with the Minister of Community and Social Services in terms of our concerns about the withdrawal of the ministry from this whole policy area.

We saw it gradually happening since 1991 and we felt there's a whole area in which the ministry is abdicating its policy responsibility, and feel that jointly the two ministries and the planning agents in the community could do a more effective job.

Mr Jackson: The situation that you're suggesting, the scenario that you paint, would indicate that with the dominance of the health model and the absolute power of the government in terms of appointing people to DHCs -- and it's fair to say DHCs are institutional and professionally dominated. They are in my backyard, they are in most people's backyards and they're all political appointments.

I'm concerned about the MSAs now. You're by extension suggesting that the MSAs are going to reflect this as well, and several organizations that have come before this committee in just a day and a half have expressed the same fear.

According to the legislation, should that be more clearly set out as a solution? What you're suggesting simply is it will end up being that way, given the way the legislation's written. Would you like to see it in the regulations so that clients and social service support workers are represented more equitably?

Mr Clutterbuck: More equitably, actively and meaningfully involved in the process of designing and implementing multiservice agencies, if that's the route that's going to be. Our concern is that there is not an awful lot of specifics about MSAs except the powers in the actual bill, and that the actual design features, although there's been a lot of study and a number of options developed and discussed -- the actual uniform design for the province probably doesn't exist. If we actually went on a community-by-community basis, you might get quite diverse and innovative forms of coordinating bodies at the local level. Some of them might actually choose or prefer to be more brokerage than actual direct service multiservice agencies.

We think that the government has heard from the community such a diverse range of possibilities that it can't actually create one uniform model for an MSA, and that's why it's not there. That suggests to me that if the government really were to allow the community to work effectively with its planning bodies, in fact we might get quite an enriched myriad of options that would create the policy framework by their common features, and that's not being allowed. Essentially, that's left up to the minister right now whether that can happen.

Mr Jackson: Finally, I just want to respond on your final point because, like many people, many legislators who are here before you today in this committee, we also toured the province and listened to presentations on phase 2 of long-term care, Bill 101. I recall very vividly in northern Ontario several communities where the planning council, and Lakehead strikes a chord in my memory, was intimately involved in the planning and integration. They were very, very excited that even though Bill 101 was institutional, they had already been developing models in accordance with the kind of vision you just referred to.

It's unfortunate we're not going to be televised when we are in northern Ontario in those communities, but I suspect there's going to be some very concerned people who've put four or five years of their life into planning towards one vision and now to have it disrupted by this legislation. But that's exactly your point, that what is unique to northern Ontario was being developed up there but doesn't fit the model of this legislation. I thank you on behalf of those other planning councils for putting that in perspective for this committee.

Ms Carter: Thank you for a very clear presentation. I certainly have a very high opinion of the social planning council in my own area of Peterborough and I certainly believe you should be having input.

We certainly do have the goal of integrating health and social services, and I think if you look at the basket of minimum services that the MSAs will have to offer, you can see that they are integrated services, so in that sense the integration is there. I would also just like to say that the government as a whole does have a prevention strategy to do everything we can to prevent people from becoming sick in the first place. Of course, as you know, that includes almost everything, things like better housing, providing more jobs, clean air, water and so on, so I think we're active on all those fronts.

Could you tell us what changes or additions you could make to those suggested services to provide what you feel is missing?

Mr Clutterbuck: I believe in my brief I actually looked on the four types of services as being a useful way, a helpful way in which to organize the range of services that are possible. I know the regulations do provide for additions within those four categories as well, which I think should always be left open, and that's a good thing. I don't have any particular difficulty, although I understand some other members of the community do, around what is identified in those four types of services. In fact, I think that's the hopeful sign, that there's some kind of integration potential here.

My concern more is with how a service system will materialize to have an adequate resource base in those four service areas over time. It's not so much with the definition of what should be available; it's more with how that might actually be realized.

For example, housing is in there and I have some difficulty in trying to imagine what greater expertise the Ministry of Health has in implementing social housing or housing programs than a lot of people in community support bodies across the province have with respect to providing supportive housing models for people with disabilities, for people with other forms of re-entry needs and that type of thing.

I think in fact the Ministry of Health has probably more limited expertise in that area, except for perhaps in mental health housing, and that we're leaving out a whole other knowledge base, an experience base that should be, through the Ministry of Community and Social Services, brought together.

Ms Carter: Of course, in practice, ministries do have to work together. You can never integrate everything.

Mr Clutterbuck: It's very important from our point of view that the Minister of Community and Social Services on this issue not be reported to or given progress reports on the development of long-term care, but that he and his officials and his networks in the community, which include ourselves, are actively involved in the planning process and in joint policy decision-making.

Ms Carter: You also made some comments about the membership of district health councils, and I think it is a concern that has certainly come up this morning at this committee, that there is a stipulation that there be consumer representation and we're not quite sure that has been adequately defined or that there are in fact sufficient numbers of genuine consumers.

There is an opportunity under the bill, to some extent, to refashion the district health councils and make sure that the membership is more representative. I wonder what suggestions or recommendations you would have about that, so that we could have better integrity in the health services.


Mr Clutterbuck: I know that district health councils -- at least the Metro one here -- have tried to be very sensitive about trying to get consumer representation, and as far as I can tell, it has been successful. To its credit, the Ministry of Health has issued a kind of direction and that's good.

At the end of the day, though, it's different to be representative of your community because you were chosen by your community, you were asked to serve by your community, versus being appointed by the government. The district health councils are still mandated agencies of the Ministry of Health and district health council members are accountable to the Minister of Health and that ministry.

We are trying to create a system here, I hope, a community service system that is accountable to the community as well in some important respects. In terms of meeting certain standards and certain levels of quality of service, it has to have some kind of accountability mechanism to the provincial government. But essentially, if it's really created by the community, it should be constituted by the community and it will then be accountable to the community.

Ms Carter: Don't you feel that's done under this legislation?

Mr Clutterbuck: I know that they have an amendment to expand the functions of district health councils. I didn't see any additional provisions besides the need to try to reflect the diversity of the community. In the end, it's still appointed by the minister and accountable to the minister.

Especially, it seems that district health councils are being set up for a longer-term, more significant role around broader integration of human services, and we would strongly suggest that if that's going to be the case, there needs to be some real look at its accountability relationships. More than just expanding its functions or having it make sure that it includes certain people by appointment, there has to be some real look at the structural nature of district health councils. We would recommend in fact that there's other experience in the community that can suggest how to create a more integrated planning mechanism.

Ms Carter: I wonder if we could ask for an expert opinion on the structure and to what extent it is community based.

The Vice-Chair: Do you want that done at this time?

Mr Wessenger: I would ask legal counsel to respond.

Ms Czukar: I would just say that there is the requirement in the amendment to the Ministry of Health Act that requires that the minister or cabinet, in making the appointments, ensure that the DHC is representative of its community.

There's a bit of a different concern here, however, regarding accountability. DHCs are advisory to the minister and they make recommendations to the Minister of Health, being appointed under the Ministry of Health Act. The delivery agencies, that is, the multiservice agencies, are accountable to the community through their memberships, which are elected by their membership from the community.

Mr Tony Martin (Sault Ste Marie): I think I understand where you're coming from in terms of making sure that the community in fact is in charge and significantly involved in the decision-making -- your comment about the district health council not really reflecting the community -- although I think in my community anyway there's been a concerted effort over the last few years to try and have that group represent the community and represent consumers, put more consumers on that group.

I was also on the social planning council in Sault Ste Marie and I know that even in that organization -- I don't know about yours. The question I have is, how is your social planning council chosen? I know that I was phoned up one day by somebody from the United Way who said, "Would you like to serve?" The social planning council in my community for all intents and purposes I think still is a body appointed by a certain élite in the community who pick and choose who they think would best serve. That still makes it somewhat problematic, and I guess the whole quest to find a real, true form of democracy. Even in the best of scenarios, where you have people elected from the community, you still only get those elected who choose to come.

I recognize that it's difficult. Even with the best of minds around this piece of legislation and trying to integrate things, I'm still not sure how you get there. Do you have any thoughts on that? I guess the direct question is, how is your social planning council chosen?

Mr Clutterbuck: We have an annual meeting and we have a nominating committee that searches for people every year. Every year we have an election. We never have strict acclamation. In other words, there are fewer vacancies than there are candidates running. So we make an assessment of our community and the nature of our community and who we should encourage to run as candidates, but we cannot guarantee who actually gets elected until the membership comes together and actually elects our board of directors.

The membership is pretty sensitive to what it needs, what its social planning council should be constituted of as well, so the membership tends to make wise choices about fairly representing the diversity of the community. We have older people, we have someone who can represent the youth constituency on our board, people from a business background, people from social services and health backgrounds.

In terms of our own council, our 40 councils across the province have actually developed a common statement of principles and values and the ways in which we work that I can make available to you; we've presented it to the two ministers. So there is some sense that we do have kind of a common set of characteristics and values and principles and ways of operating in our 40 social planning councils across the province.

Mr Martin: I'm led to believe that in fact is the process that is being proposed for local areas re the governing body of these MSAs, so I think in terms of --

Mr Clutterbuck: My recollection is that the composition of the board is left to the regulations. I didn't see that specified in the bill itself.

Mr Martin: Again, your sharing of how you do it here and how effective that is will probably be very helpful to us as we try to put those regulations together in order to make sure that the governing bodies of these MSAs are in fact representative of the community within which they are located.

The Vice-Chair: Thank you for your presentation.

Mr Clutterbuck: Thanks very much.

Mr Tony Rizzo (Oakwood): Thank you for the opportunity to place a question, Mr Chair.

The Vice-Chair: Sorry, we've run out of time. I've had two speakers. That was my mistake, Mr Rizzo. I apologize.


The Vice-Chair: The next presentation will be by a representative of Baycrest Centre. Good afternoon and welcome to the committee. Please proceed with your presentation.

Dr Moshe Greengarten: My name is Moshe Greengarten. I'm vice-president of public and community affairs at Baycrest Centre for Geriatric Care in Toronto.

Baycrest Centre for Geriatric Care wholeheartedly endorses the major thrust of Bill 173; that is, the creation of multiservice agencies in Ontario. If there is only one message we leave you with today, it is this: We believe that multiservice agencies will help simplify access to services for older adults and their families. If properly funded, they will yield positive results in supporting older adults in their own homes and communities.

There will no doubt be growing pains for all stakeholders as multiservice agencies are formed, and we must all do our part to ease the transition. Nevertheless, we believe that in the long run, the residents of Ontario will benefit from the development of these new organizational entities.

As members of the committee are probably aware, Baycrest has endorsed the formation of ethnospecific multiservice agencies in addition to geographically based agencies. We believe that such ethnospecific agencies, along with specialized satellite services, are essential to meeting the service requirements of ethnic seniors.

While the legislation is directed primarily at the formation of geographic agencies, we believe that it does not preclude other approaches. Thus, subsection 11(4) states, "The minister may designate more than one multiservice agency for the same geographic area or part of a geographic area." We support this section, which we interpret to allow for the possible future formation of ethnospecific services which might overlap with geographically based services.


We were also gratified that the Minister of Health, in her letter to the Metropolitan Toronto District Health Council, stated: "As planning consortia undertake their work they will have to consider how MSA governance, structure and policies will reflect ethnocultural communities. In addition, the DHC will have to ensure that ethnocultural communities without a geographic base are well served by the new system. I understand it is anticipated that planning consortia will identify themselves as `leads' for various ethnocultural communities. This would appear to be a very practical approach."

Other sections of Bill 173 supporting the long-term care reform principle of "promoting racial equity and cultural sensitivity" include paragraph 3 of the proposed bill of rights and the requirements for board composition. To further strengthen this principle, two amendments are proposed.

First, it is recommended that subsection 56(1) be amended to allow for regulations concerning the establishment of MSA satellite offices, as follows. We propose that the following subsection be added: "governing the establishment of satellite offices in order to address cultural, ethnic, spiritual, linguistic and regional differences."

Second, it is recommended that section 20, dealing with the development of service plans, be amended to address the specific needs of ethnic seniors, as follows. Add clause (d): "for each person who is determined to be eligible, develop a plan of service which takes account of the person's preferences based on ethnic, spiritual, linguistic, familial and cultural factors."

Section 25 sets out a framework for charging for certain services provided through multiservice agencies. We agree that there should be no charges for professional or personal support services. However, while individuals should not be denied homemaking and community support services based on ability to pay, we believe the amounts of charges for these services should not be regulated. Rather, additional funds generated through higher fees could be used for activities such as service enhancements, the development of new services, purchase of equipment, staff training or research activities.

The following amendment is recommended. We recommend deletion of the phrases in paragraph 56(1)21 "regulating the amounts of the fees required or permitted to be charged, including" and "required or permitted." As amended, the paragraph reads as follows: "requiring or permitting approved agencies to charge fees to persons receiving community support services or homemaking services under specified circumstances and prescribing the manner of determining the amounts of the fees to be charged."

On a further subject, Baycrest objects to subsection 58(3), which gives the minister power to "take control of, operate and manage an approved charitable home for the aged." We believe the Charitable Institutions Act currently incorporates sufficient safeguards for residents of charitable homes for the aged and the general public. These safeguards include the requirement for service agreements between charitable homes for the aged and the crown; the power of the ministry to withhold or reduce payments if the charitable home for the aged breaches its service agreement; fines of $5,000 to $10,000 for certain offences; sweeping, and some would say punitive, inspection procedures; and the power of the minister to suspend or revoke approval. Under these circumstances, the subsection in question can only serve to alienate the volunteer boards of charitable homes.

The following amendment is therefore recommended: that subsection 58(3), consisting of a proposed section 11.1 of the Charitable Institutions Act, be deleted.

Mr Jim Wilson: Thank you, Doctor, for once again appearing before the social development committee. I guess because you just proposed it, I'm a little confused on what you're suggesting with respect to fees and the regulatory powers in paragraph 21 of section 56. I guess I need you to throw that by me again. As I understand what you've just requested, you'd like it left up to the MSAs to set the fees, strictly. Would that not lead, though, to different fees in different parts of the province for some of those services?

Dr Greengarten: Yes, that is correct. We would recommend that, and we agree it could result in different fees in different parts of the province, as we have today.

Mr Jim Wilson: Can you give us a further justification of why that should be done?

Dr Greengarten: We would argue that a province-wide fee does not take account of regional differences, of differences in various communities to pay for services, of organizations' abilities to be creative in generating revenues. I think it sets limits on organizations, on voluntary organizations in particular, which aren't required.

Mr Jim Wilson: Do you have any idea how the residents of Baycrest would feel about your proposal?

Dr Greengarten: We're not talking about the residents of Baycrest; we're talking about the clients of Baycrest who live in the community.

Mr Jim Wilson: I'm sorry, yes.

Dr Greengarten: As you heard earlier from a group representing senior citizens, I think if you ask organizations representing senior citizens, they have a responsibility to reflect the view that there shouldn't be any user fees at all. I think we're living in a society where that's becoming increasingly difficult to sustain as public policy and I think individual senior citizens and their families recognize that they don't expect the full burden to be carried by the public purse.

Mr Jim Wilson: It's almost a moot point anyway. There are millions of dollars worth of user fees in the system now.

Dr Greengarten: One of the difficulties that we face is that the imposition of limits on fees, we believe, will reduce the existing funding level available to us and to other agencies, that we will lose revenues as a result of the imposition of fee limits which will not be supplemented through additional government support. That will have an impact on our clients which is significant.

Mr Jim Wilson: Could the converse not also occur, though? If the government discovers you're bringing in all kinds of money through fees that are above the provincial average, for example, it may roll back what little support it's giving you now anyway.

Dr Greengarten: It's possible that could occur, but as we've recommended in our paper, there are many areas that additional fee revenues could support that could enhance services and would be reasonable areas for support, including research, purchase of equipment etc, which would not have to be recovered by government.

Mr Jim Wilson: So the bottom line is there are going to be fees, obviously, that's here in the act, but there should be some local autonomy with respect to the levels.

Dr Greengarten: That's correct.

Mr Jim Wilson: Could you explain to me what the implications of the changes to the charitable homes for the aged are once again?

Dr Greengarten: One of the paragraphs of Bill 173 deals with certain new parts of the Charitable Institutions Act dealing with charitable homes for the aged. One of these sections, subsection 58(3), gives the minister power to "take control of, operate and manage an approved charitable home for the aged," under certain circumstances. We believe that power is not necessary, that there are sufficient powers in the Charitable Institutions Act and that this additional section can only serve to alienate volunteer boards of directors.

Mr Jim Wilson: I'm glad you brought it up. Mr Chairman, with your indulgence, perhaps I could ask the parliamentary assistant why that section is in there. It seems to me when you read it -- I read it again last night -- it's a fairly draconian section. It sounds that with fairly dubious reasons the minister can come in and take over the operation of a charitable home. Also in your answer to that I need a clarification, because the wording of the act, as proposed here, is that there has to be some approval from the board of the charitable home at some point also. I was a little confused as to what the mechanism is, exactly how the minister takes over the operation.

Mr Wessenger: First of all, this power does presently exist under the act relating to the Ministry of Community and Social Services, so the takeover part already exists. We're not creating a new power under this act; we're just putting it under the provisions of the Ministry of Health, as distinct from the Ministry of Community and Social Services.

Perhaps I'll ask legal counsel who may wish to add something to the comments, but I think we can understand a situation if you had a charitable home, for instance, that was in an insolvent position or was unable to deliver the service, you'd want to make sure that service was continued so the residents would not be left without service. I don't know whether legal counsel can add anything else to that or not.


Ms Czukar: I would just say that it does exist currently under the Ministry of Community and Social Services Act and since these institutions are now under the administration of the Ministry of Health, we needed to amend the act to make it clear that this takeover power still exists in relation to these homes and the provision -- I think you must be referring to 11.1(1)(a), which talks about the minister taking control of, managing and operating a home if the home consents, and that's a situation where the home might, for some reason, not be able to operate and say, "Minister, would you take control?" and the minister wouldn't have the power to do that unless it were given. So that's why that's there.

The other conditions under which the minister can take control of and operate a home are where the physical state of the home or the manner of operation is causing or likely to cause harm to people, and obviously that's a situation where the ministry might have to act very quickly, rather than just revoking an approval or suspending an approval. In the meantime, the ministry might need to ensure that people are going to be looked after.

I would also point out that other subsections of that section require a hearing to be held as soon as possible after any of those of powers are exercised.

Mr Jim Wilson: I guess the reason it raises suspicions for me in this act is, why wasn't it done under Bill 101? To have it suddenly appear here just baffles me.

Ms Czukar: The transfer of administration from Comsoc to Health hadn't occurred at the time Bill 101 was being discussed.

Mr Malkowski: Thank you for your presentation. I know Baycrest has an excellent reputation for volunteerism and for local fund-raising, and one way that MSAs can build on this tradition is perhaps to have programs continue to have their separate identities and yet, at the same time, they could share common local community boards. What other ways can you see other traditions being reflected?

Dr Greengarten: I'm not sure that I understand the question completely. As we see it, the proposal for multiservice agencies will allow for volunteer boards of communities. They will allow for volunteer governance and we support this approach.

You may be referring to our comments about the needs of serving ethnic communities, and in that respect we believe that one approach to doing this is by allowing for ethnospecific multiservice agencies which will serve larger ethnic communities. Another approach is to allow for ethnospecific satellites which may be part of geographic multiservice agencies. But the key here is to foster within communities, regardless whether they are geographic, ethnic or perhaps based on some other basis, a sense of ownership and a sense of pride in their institutions.

Mr Martin: I just want to say, first off, that given the pattern so far, your stance, being a provider, is a bit of an anomaly. I don't know if that's going to set a trend for the rest of the hearings, but your support of this bill, being who you are, is for us on this side actually rather refreshing, and we thank you for that.

But I do have some questions, given that you are a provider, around how you've come to be able to support the concept of MSA, and given that in the regulations, or proposed regulations, there will be a 20% window for providers in this, how you see yourselves fitting in and continuing to offer the services that, as Mr Malkowski has referenced, you obviously deliver very well?

Dr Greengarten: By whatever name you call it, a multiservice agency or some other name, we have been endeavouring to develop what we call a continuum of services to our community for many, many years, many decades. We believe that the multiservice agency concept comes closest, in what we've seen, to approaching the kind of spectrum of services available in one place for seniors and their families, through one contact, is as close to that model that we've been trying to develop as anything we've seen, so that's why we support it.

Where exactly our organization will fit in is a question that will have to be determined through community consultations and community planning. We will continue to exist in some forms providing some kinds of services regardless of what happens with multiservice agencies. We hope we will be part of the multiservice agency framework within our geographic area, but regardless, just in principle we believe that it is a good way, and the best way so far, of providing service, of organizing service so it's understandable to the consumer.

Sure, from the provider perspective it's going to create problems. We will have our own vested interests for different reasons in being supportive of or against multiservice agencies. But the bottom line is that we, particularly our boards, our volunteers, are in this area to ensure that consumers in our communities receive the best possible service, and in that context, and trying to wear that hat, that objective hat, this is a positive step, in our view.

Mr Martin: Do I have some more time?

The Vice-Chair: For a very short question, one additional question.

Mr Martin: A very short question: There's the question again from providers when they come that somehow in this move to an MSA system they will lose the essence of who they are or they will not be able to transfer what somebody referred to as ethos, as reason for being, a spiritual dimension that often flows through. How are you going to deal with that?

Dr Greengarten: We're a large organization, and I'm not sure we're in the same situation as many of the organizations that are coming before you.

But on the issue of ethos, of a sense of an organization, over the course of the history of the voluntary sector in this province, voluntary organizations come and go. Volunteer organizations change their missions to reflect changing circumstances. An organization that may have served, let's say, certain health needs many decades ago didn't have to do that when hospitals came along and medicare came along, so their mission could change or they could go out of business as a volunteer organization. Many of them changed their missions, and that has gone on. So in taking the long view, organizations have changed, their missions have changed, and that is a process that will continue to go on whether there is Bill 173 or there isn't Bill 173, because circumstances will change in our larger communities.

I would hope that organizations, and particularly the voluntary boards of organizations, will try to see the larger good that could come out of this, that they can continue to maintain their sense of purpose and their sense of mission, either through a new form of organization, an MSA, or in developing new missions and providing new services that will be very worthwhile, I'm sure.

Mrs Sullivan: I'm interested in the amendments that you've proposed, and we are certainly supportive in particular of the amendments 1, 2 and 3 that you've put on the table. I think in particular amendments 1 and 2 are interesting, because they address some of the issues that have been very much on people's minds before the hearings, and in fact what I see them doing, these amendments, is enabling a far more sensitive surround to the MSA bureaucratic structure, frankly.

I recall in Bill 101 Dr Bob Rumball appeared before our committee, and I asked him at the time if he felt that the Bob Rumball Centre for the Deaf might be bidding to become an MSA on its own for a particular linguistic cultural community. He said at the time that he thought that might be a very good idea and it was something that was certainly on their mind.

Saint Elizabeth's and the Catholic agencies have appeared before the committee indicating that they will go out of business with this MSA bill. You say that Baycrest is in a different situation. If you are not named as an MSA, I suspect that you may well go out of business too. I think these amendments enable you to stay in business and continue to provide service. In fact, you become not only a regional deliverer of service but one where the integrated services in the history of your own organization and its own development will be recognized. I'd like you to comment on that.


Dr Greengarten: We are proposing these amendments because we believe that they will help to support the approach we've taken, the tradition of serving the Jewish community in the greater Toronto area. We believe that they, if approved, would help to put into place a framework which will not only help us but other community-based organizations be effective partners in the development of the multiservice agency framework. So that is why we have put them forward; you're quite right.

Mrs Sullivan: In the absence of this, particularly amendments 1 and 2, do you see yourself ceasing to function as part of the public component of long-term care delivery?

Dr Greengarten: It's hard for me to speculate on that. I think, whether they're passed or not, we will work tirelessly to try to ensure that our community is served.

Mrs Sullivan: But in the absence of this kind of an amendment, basically your services would then have to be directed to the fee-paying client --

Dr Greengarten: I don't believe that's the case.

Mrs Sullivan: -- unless they were purchased, in that 20% component, by an MSA.

Dr Greengarten: I'm not sure that I can respond to that question.

Mrs Sullivan: I think you'll find that's what the scenario is.


The Vice-Chair: The next presentation will be made by a representative of the Association of Allied Health Professionals. Welcome to the committee. Please introduce yourself for Hansard and proceed with your presentation.

Ms Catherine Bowman: My name is Catherine Bowman, and I'm the executive director of the Association of Allied Health Professionals, or AAHPO. We are a union which represents over 1,400 health professionals across Ontario. Approximately three quarters of our members are in hospitals; the remaining one quarter are employed by public health units or boards of health. It is this latter group of employees that will be most directly affected by Bill 173.

In health units, we represent 11 out of the total 38 home care programs across the province, or approximately 30%. In our brief, we've given you a list of those programs. They're located primarily outside of the large urban centres, with the exception of the Ottawa-Carleton region.

The main classifications which we represent which will be affected by the bill are: case managers, nutritionists and dietitians, occupational therapists, physiotherapists, social workers and speech pathologists.

We generally support the introduction of this legislation that will make MSAs a reality. There has been and continues to be a great deal of uncertainty in the community about MSAs and the implementation of long-term care reform, and generally we agree with the five stated objectives of Bill 173, namely: the one-stop access; improved community-based service; consumer-focused system; improved and consistent accountability; and local, community-controlled planning.

However, we do have some concerns about how these objectives will be met through the legislation, and we believe that there are a couple of important issues which are not dealt with in the bill. It's on those points that our submission is concentrating. The main points which we are covering in the bill have to do with: better definitions for the provision of professional services; additional criteria for the approval of agencies; the need for fairer consideration of boards of health as designated MSAs; the need to further restrict the purchase of services, and included in this, the deletion of two of the three exceptions on purchase of services. We believe there needs to be some clarification in the appeal procedure, as well as a qualification on the repeal of paragraph 5, section 5 of the Health Protection and Promotion Act. We'd also like to talk a little bit about district health councils and the need for protection for existing employees in community-based agencies. Because of the brevity of the time, I'm not going to go through my brief in detail. I'll leave that to you to peruse at your leisure, and I will just highlight some of those points.

One of our main concerns is the assumption that everyone is making, that alternative, presumably lower-cost, workers can be trained to provide professional services. This we believe moves against the direction in which the government has been moving through the Regulated Health Professions Act, and although the compendium that accompanied the bill talks about that act and recognizes that there are certain restricted tasks, there is no reference to this in the bill. We believe that's an oversight, that there should be some recognition that in the provision of professional services there should be some minimum qualifications that should be met.

Although we recognize that professionals may on occasion train family members or may train lesser qualified people such as homemakers to provide certain specific treatments, we believe that should always be done on an individual, case-by-case basis and then it's not something that people can be trained in a matter of weeks to be a generic worker to do everything for everyone in the home. So we have some serious concerns regarding that and believe that the bill should be amended to provide similar provisions to that in other acts. We recognize that there is provision in the act for regulations which may prescribe qualifications or requirements for service providers but we would like to see that strengthened.

In terms of the approval of the agencies, we have some concern that the minister will be looking at the financial capabilities, the good intentions and suitable premises of agencies, but there's nothing to do with the human resources, and we believe that the success of an MSA is dependent on the quality of the staff who will be delivering those services and that's something that should be considered in terms of the approval process. I think there's going to be a tendency for people to look at the financial bottom line and therefore for employers to try and shave costs by using less qualified people. We believe that is not in the best interests of consumers and we believe that should be considered in the approval process.

As far as boards of health are concerned, the bill provides right now that boards of health or municipalities should only be considered after all other agencies. We believe that this should be deleted and that they should be allowed to compete along with other agencies. I believe that the compendium states that this is to ensure that the composition of the MSA meets the requirements of the act, yet it ignores the many years of valuable experience both administratively and in the provision of services, and these people should not automatically be placed at the bottom of the list. Just as there are exemptions elsewhere in the act, recognizing that it may take four years to get up to the proposed limit on purchased services, there could also be an exemption for boards or municipalities in order to give them time to alter the composition of their boards to come in line with the direction desired by the government. This would be more practical and less expensive than requiring entire new agencies to be set up.

In terms of the purchase of services, the Implementation Framework, June 1993 document stated that the purchase of services would be the exception for MSAs, not the standard. It also stated that there would be a 10% maximum limit for purchases from commercial, for-profit agencies. In Bill 173, the government is suggesting that agencies be allowed to purchase up to 20% of their services and it goes on to provide some exceptions to this which in fact means that agencies could purchase significantly more than that 20%.

In addition, there's no mention of a restriction on purchasing services from commercial agencies nor even a stated preference for not-for-profit agencies. We believe that this is a backward step. We have some very serious concerns about the proliferation of private, for-profit health care and also the implications that contracting out have for job security for workers. We think that contracting out can compromise the quality of service, especially when we're talking professional services. In many cases, several professionals may be seeing the same patient at the same time and it's imperative that they coordinate their treatment plans, and this is best done when people are employees of the same organization. Contracting out just increases the already difficult communication problems. Also, agencies do not have the same control over the quality and standards of service that are being provided.

The other concern we have with respect to purchased services is that there's no requirement that they be purchased from approved agencies. The bill just refers to service providers. Again, we believe that if they are going to be purchased -- and we believe they should be much more strictly limited in the bill -- then those purchases should only be from approved agencies.


The two exceptions that we have problems with are the ability for agencies to purchase services to cover short-term absences and to purchase services from individuals. Neither of those are to be counted towards the 20%, and we believe that that undermines the purpose for having a limit in the first place.

As far as covering short-term absences, it's common practice in hospitals and other health care agencies to employ employees on an as-needed basis. This could easily be done by MSAs and it would ensure that the relief staff are fully oriented to MSA procedures and meet the qualifications and standards of service required. It would also be less expensive. The same is true in terms of purchases from individuals. Again, we believe those exceptions should be deleted from the bill.

We have some concerns, in terms of the appeal process, that this will create an unnecessary, time-consuming and bureaucratic process. We agree that people should be able to challenge decisions, but we have some real concerns that professional judgements are going to be questioned as well and the impact that this will have on professionals being reluctant to exercise that judgement in order to avoid the threat of a lengthy appeal. We feel that there needs to be some clarification in the appeal process with respect to professional decisions regarding whether treatment is or is not warranted or the alteration of treatment plans and that perhaps an ombudsperson would be a better route to follow than a full appeal board in appealing these kinds of decisions.

With respect to paragraph 5 of section 5 of the Health Protection and Promotion Act, this may be a technicality but we're concerned. This requirement in the act requires boards of health to ensure the provision of home care services that are insured services, and our concern is that there may inadvertently be a gap created if this bill is passed, there's a repeal, and there are not MSAs up and running in the community to take over the home care services. So we believe that that should be qualified and only applicable to boards of health where an MSA has taken over the provision of home care services.

As far as district health councils are concerned, we support the premise behind them, but we have some serious concerns about the current composition of DHCs. Along with other unions, we believe that unions and front-line health care workers are very poorly represented at the present time and there needs to be much broader representation on DHCs.

We do support the requirement for providers of health services to provide the minister and DHC with plans and other information upon request. We believe that this merely brings the community in line with the hospital operating plan process, which has been in place since November 1991 and which has led to a greater involvement of both internal and external stakeholders.

In terms of looking at the appointment process to DHCs, we believe that it should not only reflect the diversity of the population, but it should also reflect the diversity of stakeholders in the health care system, and we believe that each union should automatically be entitled to sit on, at the very least, DHC subcommittees where they are representing health care workers in an area and that labour should be guaranteed a number of appointees on each DHC.

What is missing from the bill, and we believe that this is a very glaring omission, is job security for existing employees working in agencies in the community. Throughout the consultation process, fair treatment and job security for employees was promised, and the bill is entirely silent on this.

We believe that there should be no question that, as services are moved from an existing agency to an MSA, the employees currently employed in providing those services should be guaranteed continued employment and that they should suffer no loss of salary or benefits. We believe that it's very humiliating to have to apply for your own job that you've been performing for years, and we don't think the MSAs should be able to take advantage of a technical change in employers to replace existing employees. The unions have been requesting of the government a comprehensive, enforceable provincial employment security agreement for the entire health care system, but since we have not been successful in achieving that, we believe that it's crucial that Bill 173 include provisions which provide this type of protection to employees who are going to be affected by the long-term care reform.

The final point we wanted to make is not really specific to Bill 173 in that there are no real amendments that we can suggest for it, but there is an underlying assumption that this legislation is dealing primarily with the elderly, adults with physical disabilities and people who are trying to remain independent in the community. But the reality today is that home care services very much have to do with acute care and rehabilitative services and the provision of paediatric services to students in schools. We believe that the needs of these people are sometimes very different and that, unlike the assumption that's made that institutional care is a last resort, for these people it may be the preferred resort, and what we are concerned about is that the system must be flexible enough to accommodate that.

Really what we're talking about is where the MSAs fit in with the continuum of health care in the community. We're seeing more and more demands being placed on the home care programs as hospitals are discharging patients earlier and earlier and sicker and sicker, so we believe this is a very serious concern that the government has to take a look at. Otherwise we are going to see early discharge patients drawing on resources that have been promised to the elderly and adults with disabilities to allow them to cope more independently in the community.

I believe that covers the main points. We think it's very important that there be a framework in place as quickly as possible to provide the kind of protection to both the public and the employees working in the system than has been promised through the consultation process.

Mr Jackson: Thank you for your presentation. There have been a lot of presentations so far that speculate about the impact of this, and I think you've come close to expressing some concern in your final comments about the impact of early discharge from hospitals. That has not really been discussed. The seniors have indicated that type of citizen is being discharged far too early and in much sicker condition, I think was the way they referred to it.

If you take one large step back from Bill 173 and put it in the context of all the things that are happening to ratchet down health care at the hospital level, and the lack of bed growth for chronic care across all levels in all sectors, there are reductions. Chronic care hospitals, regular hospitals, nursing homes, homes for the aged, all of them are in reduction mode.

Some have gone so far as to suggest, and I think you almost did, that the MSAs will be predominated by being the conduit or the discharge for people who are in hospitals -- in fact there'll be a shift of emphasis from those persons who are truly in a case of community need, where they're not necessarily hospitalized but their condition is degenerating to a point where they need intermittent services -- but that in fact the institutional-based protocols that are calling upon the MSAs will rise to predominance. Some of them have even gone so far as to suggest, if you are discharged from a hospital you get the services, but if you're sitting out in the community in a lessening state, then you're just going to have to wait months, as is the case now, for appropriate services to be put in place.

Is that part of your concern, and are you seeing evidence of it as we're starting to see evidence of it from when we talk to home care, when they say a disproportionate growing number of our cohort of services are people being discharged from hospital and not necessarily people who are in need of the services simply because they're frail and elderly and unable to get into any form of institutional care?

Ms Bowman: Certainly we are concerned that our members are seeing more problems with people who are being discharged from hospitals prematurely. A lot of the difficulty comes from inadequate discharge planning that the services may have been able to have put in place if they were kept in hospital just a little bit longer to allow that kind of coordination to take place. What's happening instead is they're being discharged, sent home, and it's a crisis situation that people are having to deal with in many instances.

We do have some concerns but nothing we can document. We're attempting to try and gather some documentation on the kind of anecdotal evidence that we have. So, yes, we are concerned about a sort of double standard being created. As patients are discharged from hospitals into the community, it's the premature discharges that we are concerned about. Some people are ready to go home and are quite able to cope with just some assistance or some professional services with homemaking and personal support services on a short-term basis.

It's where the MSAs fit into the continuum of health care that we are concerned about. They are not the be-all and end-all. There will always be a need for facility care and there will always be a need for individuals, especially those who are living on their own independently who have no family on which to depend. They are our concern.


Mr Jackson: I recognize your comments about the labour representation and worker representation on the MSA boards, and I think that's clear and understandable. I want to set that aside, though, and talk about the institutional and professional imbalance which is being referred to -- it has come up in three briefs today and about four yesterday -- to the extent that just as hospitals have a significant impact on district health council decisions, again hospitals will have a significant impact, through composition and allegiance, if they're involved with the MSAs.

Certainly, if you look at where people are being discharged into institutional care, there is primacy given to patients who leave a hospital to go into an institution rather than family in crisis, where mom can no longer take care of dad so they're on a long waiting list to get into an institution. I see the influences of hospitals through discharging into institutional care and my fear is that we may see something similar.

Ms Bowman: Hopefully, the placement coordination services will help to alleviate that problem, whereby the admissions into institutions will all be funnelled through the placement coordination services.

Mr Jackson: But who runs placement coordination services?

Ms Bowman: At the current time a lot of them are located in home care programs, and it's my understanding that they will transfer with those home care programs to the MSAs. That's not the case in all instances but, as I said, our concern is where the MSAs fit into the system as a whole, and this has to be looked at from a system-wide perspective and not just a community care perspective as far as the elderly and disabled adults are concerned.

Mr Martin: I want to thank you for your support of this legislation and your encouragement, and certainly understand some of your questions and concerns. That really is what these hearings are about, so that we can fine-tune and find ways of making it more responsive. Certainly I agree with your recommendation that we need to somehow find some flexibility in this, but that will very much, from my perspective, depend as well on reasonable people out there applying some of these things. We can only set so many parameters and frameworks around things and then we expect that reasonable people out in the field will make intelligent, reasonable decisions. When you lay out a scenario where somebody is sent home from hospital with two broken arms, I ask myself who would do that.

Ms Bowman: It was a case that was relayed to me as early as two days ago.

Mr Martin: Yes, and I don't know how you put in legislation things that will stop that kind of business from happening.

Ms Bowman: Having discharge planning is how you stop that from happening. Before people are sent home, if somebody gets to talk to them and identify what needs they have and to make sure that they are not going home alone.

Mr Martin: Anyway, my questions were around your wanting further protection for the people already working in the field. We've certainly heard so far, in the two days that we've had hearings, that same concern raised by some folks -- actually, this may be a bit strong, but an accusation that the government is in fact intending to employ the more professional sort of unionized organized people who are in the field now as opposed to the myriad of others who are out there who will be affected by this legislation one way or another. I mean, there's real fear.

Does your concern for the workers in the field now go beyond the organized unionized groups that are there now or is --

Ms Bowman: Certainly, because I believe that the organized unionized groups have some formal protections through their successor rights under the Labour Relations Act, and we will be pursuing those rights to the best of our ability. But to a large extent the community agencies are not organized and those people are very susceptible. They don't have any recourse to fall back on to insist that they get to keep their jobs, in essence, that they are performing now when those services or jobs are being transferred. We believe the people should be attached to the jobs and, if the jobs move, the people should move.

Certainly there will be questions to be answered in terms of bargaining rights and organizing and all the rest of it, but there is a large group of unorganized workers out there who are very vulnerable as well and require the protection in the act to ensure they get to keep their jobs.

Mr Martin: How do we sort out, then, in terms of saving everybody's job, some of the philosophic differences that are now in organizations? Like this morning, we had a woman present who was very strong in her feeling that it isn't necessarily the most educated person who's going to do the better job in terms of home care outreach; it will be somebody who has that sort of heart, you know, who really wants to do it, who understands. How do you sort all that out?

Ms Bowman: I think it depends on the job that you're talking about. I feel quite strongly that if you're going to perform physiotherapy services or occupational therapy services, then you'd better be a qualified, registered occupational therapist or physiotherapist. I don't want somebody who isn't qualified, who isn't registered with the college, performing treatment on myself, members of my family, members of the community.

There are lots of other jobs being provided in the community that may not require that level of expertise, may not require that high level of professionalism, and that, yes, are being performed right now. I don't think the people who are performing those jobs should be thrown out of their jobs and replaced by someone else. There has to be some compassion and some flexibility in the system.

What we were looking for is something in the bill that would create an obligation on the part of MSAs to absorb not only the services and the jobs but the people attached to them, and then sort it out after the fact. But people have to have some sense of security and some certainty, and right now there is very little certainty out there in terms of what is going to happen to people when these MSAs are created. So I think there is a real need for the bill to address that.

Mr Martin: Just one other piece, if I have some time: On the inclusion of your group on the DHCs and on the governing boards of MSAs, it becomes quite cumbersome if you try to include everybody. I know from just watching in my own community efforts to try to include consumers. As soon as you get more consumers than you have providers, you have a problem on your hands because the balance of power is shifting and all of that.

Any thoughts on how logistically we might include some of the folks that you're recommending be on those organizations at this point and still maintain that balance and still have this be consumer-driven?

Ms Bowman: You have to recognize that union members are consumers as well, and the purpose of a union is to represent front-line workers, so I think that representation on DHCs and MSAs should be drawn from unions. I know there's been a real difficulty on the part of the government and some other organizations in recognizing that, but if people want a voice and they want to be represented, they join a union. If they don't, then they allow the employer to speak on their behalf.

In looking at the composition of these various organizations, I believe that if you have a cross-section of unions, you'll have a cross-section of front-line workers. It's important that you have front-line workers who are involved in the delivery of these services, and not just your administrative types or your management types. That's where you will get improved quality in the decision-making.

I don't think there's a need to have to look to unorganized workers to sit on here. Yes, from a consumer point of view, but from a provider point of view, we believe the representation should be drawn from organized workers and from unions. That's their purpose. They are there to speak on behalf of all workers, and I think have done a very good job when they are sitting on these committees.

The difficulty is there are not enough of them, and there has been a perceived conflict of interest in having union members sitting on DHCs, but there's no conflict having hospital administrators or doctors, who are driving the system, sitting on DHCs. So that's a double standard as far as we're concerned.


Mr McGuinty: Thank you very much for your presentation. Your presentation here constitutes a very effective -- what would I call it? -- expression of advocacy on behalf of the people you represent, and I'm personally a little bit disappointed that it did not make greater reference to the broader public interest and the consumer, the end user.

Your presentation is a bit of an anomaly in the sense that you are actually asking that the government reconsider its 20% cap on outside services and you're suggesting that it in fact be reduced. You're also saying if the government is going to allow MSAs to purchase services, that preference should be given to not-for-profits.

If I'm a consumer, if I'm a senior, how would those amendments help me? I can see very well how they will help you and the group you represent, but how do they help me as a senior?

Ms Bowman: I'm sorry that you've interpreted this submission as being entirely in our self-interest. Because of the time allotted I necessarily concentrated on issues that were of direct concern to our organization and our members, but in so doing I do believe it will lead to a better system.

In terms of the not-for-profit issue, we believe that for-profit drains money out of the health care system. This is taxpayers' money that we're talking about, and we believe it should be used for the provision of services. We have some real concerns about two-tier systems and all the rest of it. I think you can get a high-quality service from a not-for-profit agency.

Mr McGuinty: Correct me if I'm wrong, but I thought the money that the province pays to for-profits for services is exactly the same as we're paying to not-for-profits.

Ms Bowman: That's true. I guess the question is that the profit has to come from somewhere and I'm not convinced that the profit comes simply from efficiencies. I think that's perhaps a fundamental concern, as well as the impact of the people who are delivering those services. It's a fundamental philosophical -- we do not believe in for-profit health care. It was our understanding that this government, at the beginning of the consultation process, also had a preference for not-for-profit health care, so we were disappointed not to see that show up in the bill.

Mrs Sullivan: I'm interested in a technical proposal that you've made in your brief. I haven't quite finished going through the entire thing, but it's with respect to section 59, which would repeal the requirements of the boards of health to ensure the provision of home care services that are insured services under the Health Insurance Act.

You've made what I think is a valid point, indicating that until an MSA is up and functioning and fully operational and the home care program working underneath it, it doesn't make sense to repeal that provision. I wonder if the parliamentary assistant would comment about what the intentions of the government would be with respect to proclaiming that section.

Mr Wessenger: I'm going to ask legal counsel to comment on this issue.

Ms Czukar: The provision for approved agencies in the bill is for exactly that reason, to allow existing programs to become approved and to continue to operate until such time as MSAs are designated and those programs would be operated by MSAs.

Mrs Sullivan: But in this case the repeal is in advance of the operation of similar programs by an MSA.

Ms Czukar: That's correct, but the agencies that currently operate the home care programs can become approved agencies under Bill 173 and can perform all the things that they're doing now as an approved agency under the bill. The repeal of this section really is just to remove the statutory obligation on boards of health to be operating home care services when that's going to be done by approved agencies and MSAs. It's not fair to them to require them to continue to provide this.

Mrs Sullivan: All right, then let's just walk through this in a step-by-step way. Now, in many communities, home care is provided by the boards of health in those communities. Is there a guarantee that the minister will make every single board of health that currently operates a home care program an approved agency?

Ms Czukar: There's no guarantee in the act, but the minister is going to need to do that to ensure that the province continues to be covered by home care agencies in every area where they currently exist.

Mrs Sullivan: We may better have a little look at this part, just to be certain that if the bill comes into force and the MSA is supposed to be organized in a community, with a board etc etc etc, and the minister hasn't designated the board of health as an approved agency and this particular section is repealed, then the board of health could say, "Sorry, we're out of home care" before the MSA is up and running. Listen, I don't trust anything around here.

Mr Wessenger: I think that's theoretically possible, but the normal process would be that the approval would be simultaneous with --

Mrs Sullivan: The normal process?

Mr Wessenger: The policy adviser might be able to add something.

Mr Geoff Quirt: Just by way of clarification, in seven or eight places in Ontario the public health board has nothing to do with the delivery of the home care program --

Mrs Sullivan: I understand that. I'm only asking about this particular section.

Mr Quirt: -- and as has been pointed out, the minister would be obligated to approve home care programs, the public health unit or the regional municipality as an approved agency to continue those home care programs until the responsibility is assumed by the multiservice agency. In Toronto, for example, the public health units aren't involved in the delivery of the home care program; an independent board does it. This obligation, while technically on the public health board in Metro, certainly doesn't interfere with the minister's ability to fund home care in Metro.

The Vice-Chair: Do you have any comments about that before concluding?

Ms Bowman: We were just raising it as a potential concern, that a health unit that may not want to continue with home care, may choose not to seek approval as an approved agency, may fall between the cracks. That was the reason we raised it.

Mr Quirt: If a public health unit or municipality chose now not to continue to deliver the home care program, no doubt other arrangements would be made.

Ms Bowman: Thank you.



The Vice-Chair: Next is the Ontario Public Service Employees Union. Please come forward and introduce yourselves, and welcome to the committee.

Mr Bob Reid: Good afternoon. We appreciate the opportunity to make a presentation today on Bill 173. I am Bob Reid, executive board member of the Ontario Public Service Employees Union, and accompanying me this afternoon is Tracey Mussett, who is a member of Local 477 at the Renfrew County and District Health Unit.

We have submitted to you a written brief which outlines our concerns about Bill 173 and the direction long-term care reform is taking. I will, as time permits, emphasize several key issues here today, and then we will be pleased to answer questions from the committee on our presentation.

OPSEU represents 110,000 public sector workers across the province. Of those, close to 20,000 are engaged in the delivery of health care services.

OPSEU members are concerned about long-term care reform and about Bill 173 because they work in acute and chronic care hospitals, psychiatric hospitals and community mental health agencies, homes for the aged, nursing homes, home care agencies and ambulance services, government-run facilities and community agencies that care for physically and developmentally disabled people, community agencies that offer wellness and recreational programs for aged persons, and government-run monitoring, compliance and support operations.

OPSEU members are the educators who train the health care workers in community colleges.

OPSEU members are consumers of health care services. Many care for elderly and chronically ill family members. Our members are community activists and volunteers. OPSEU members are taxpayers.

The reform of the long-term care system is an important and emotional issue for all our members.

OPSEU has put considerable thought into what makes quality care.

Our health care goals demand: the promotion of wellness, autonomy, independence, dignity and choice; a continuum of care; cultural sensitivity; quality, accessibility and enforceable standards; full funding; non-profit, regulated settings; and government accountability.

We believe that the reform of Ontario's system of long-term care services is overdue. The existing system is fragmented, unplanned, uncoordinated, poorly regulated and out of touch with real needs.

OPSEU has been working hard to help this government see the need for real change, change that is based on real needs of real people.

Our members support the objectives of Bill 173. We have serious concerns, however, about the gap between the rhetoric of those objectives and the reality of the process and the outcomes. We have serious concerns about the effects, the real effects, for all of us.

The rhetoric and the reality:

The government says we must build a new kind of health care system. The government says we must make the most efficient, effective use of our public resources. The government says the system must be accessible and consumer-focused. The government says it is shifting funds in the health budget so it can fund more community services to seniors. They talk about providing support to the community and families. They say Bill 173 recognizes the importance of a person's needs and preferences in all aspects of community services. They say they are decentralizing decision-making so there can be more local planning and participation by consumers. The government talks about the importance of direct involvement of front-line workers in the reform and restructuring taking place across the province. They say Bill 173 is designed to encourage and support early progress towards the establishment of multiservice agencies.

OPSEU says that is the rhetoric. We see the reality.

We see our members working in downsized facilities, afraid for the future, although they have been assured that there are new and improved community jobs coming. We see workers in the community now without the ability to bargain collectively for adequate compensation and good working conditions. We see women working in jobs with no guarantee of hours and no job security.

We see women trying to support a family singlehandedly, working part-time jobs with no benefits, now also coping with service cuts and user fees. We see workers who are expected to increase their skill and training levels to keep pace with this reform, without the incentive of an increase in compensation.

We see women taking vacation leave or leaving the paid workforce to care for family members and neighbours. We see women becoming sick themselves from trying to deal with the working stress, the guilt and the added responsibilities in their homes and their communities. We see sick and elderly people having to rely on family members or community volunteers for care previously provided to them by trained professionals in safe environments.

We see consumers and working people who want to be informed and involved in what is happening in their workplace and their communities trying to attend exclusive meetings and daytime forums with limited resources, only to be told their participation poses a conflict of interest.

We see a system that names labour as a partner and then marginalizes us. We see a reform system that fails to recognize the number of taxpayers organized labour represents. We see local planning bodies without equitable representation.

We see our members, who used to enjoy their work, who genuinely care for people, now frustrated, frightened and angered by the level of care they see given because of budget cuts.

We see women whose quality of life has drastically deteriorated and yet are still expected to offer loving and selfless care and nurturing to the entire world because it is assumed to be their nature.

We hear people talking about facilities as though they are bleak, uncaring, last-resort dumping grounds for people whose families don't want them.

We hear this government talking about "community" as though it is something warm and cosy that it just invented.

We see people living in complete isolation in cities and in rural areas.

We see a lot of people who have no idea what is happening to our health care system and what Bill 173 means because the information is not available to them.

We see a health care system that continues to discriminate against women and the elderly.

We see facility-based care being cut before fully funded community support is in place.

We see a system that fails to recognize the existing high-quality, available, well-accessed programs which are now offered by hospitals and other facilities. We see a system that expects each community to come up with its own strategies without sufficient funding, with workers and consumers left to suffer. We see communities being rushed into implementation without adequate information about transitional issues.

We see meaningful discussions about employment security being set aside, centrally and locally, as if it can be discussed later, while workers are being affected now.

We see this government offloading the responsibility for negotiating employment adjustment strategies on to the community.

We see a system that continues to try to reform itself ignoring the insights and the ideas of those who will bear the brunt of that reform.

We hear talk about better services, but we see that what is meant is cheaper service, a system driven by the corporate agenda and bottom line. We hear the panic created about the cost of the health care system. We have talked about waste that could be controlled without cutting services and without adding unemployment.

We hear the Ministry of Health say that it has determined that unemployment and stress have a negative impact on health, while it adds daily to the insecurity of workers in the health care system.

In both facilities and community-based workplaces, we see our members continue to make the system work, for the sake of those they care for, at their own expense.

We see a system that fails to recognize that user fees put the burden of cost on those least able to pay: the sick, the disabled, the elderly and low-income families.

The reality is that Bill 173 will contribute to higher health and social costs for us all. The reality is that Bill 173 reduces our right to care.

Our brief addresses these concerns more fully. I would like as a conclusion to highlight some of our recommendations regarding Bill 173 and long-term care reform in general.

OPSEU and the other health care unions have proposed a province-wide employment security agreement. Instead of trying to negotiate from scratch in each community, we believe it makes sense for all the players -- unions, government and employers -- to advance a single province-wide approach to employment security. As the Ministry of Health says it wants to maintain a quality service, and that changes in sector should not lead to unemployment for front-line workers, an employment security agreement makes a lot of sense.


Our proposal moves us beyond the social contract and provides for a neutral place to have discussions so that all unions can participate. It does not contradict any part of the health care sector agreement and builds on the positive aspects. With such an agreement, the ministry would save valuable time and money.

OPSEU supports the health sector training and adjustment program, which includes labour as a full partner. We recommend that the use of the jobs registry, matching available workers with available work, be mandatory in order for HSTAP to fulfil its mandate.

OPSEU supports the OFL-ONA proposal which calls for a nomination process, which would ensure that labour has legitimate and accountable representation on district health councils and their committees.

We believe we are the ones who should define what a labour perspective is. OPSEU members are concerned about the fragmentation of the consultation and planning process. There are many committees and advisory groups where labour has not been able to provide input. We recommend, therefore, that a labour liaison committee be established which would allow the unions to review the community services reform and implementation issues with the ministry in a more coordinated manner.

OPSEU members are very concerned about the shift of the family on to women. We have some concerns about the expectations that will be placed on communities and volunteers. We urge the government to revisit these issues with labour's input when it makes its revisions to this bill.

We thank you for your attention and we will be pleased to answer any questions.

Mrs O'Neill: I'm very pleased that you brought the case the way you did. I do think there's an awful lot of rhetoric around this bill. I think it has caused confusion and fear among people like yourselves as well as the people you work with and for.

I am very happy that you were able to put on the record that you represent 20,000 people and that your efforts to become meaningfully involved have not been met. I think that's important.

I'm glad you went into detail about the employment adjustment and compensation spinoffs because there's not much being said about that. Certainly, if the rest of the agenda of this government is to be meaningful at all, those things have to be on the table on this important issue.

The thing I think you have pointed out that no one else has is the effect this bill is going to have on women: women who are workers and women in their homes who are going to try to provide services that will no longer be there, so for that I thank you.

There's such limited time in these hearings that I have to also limit my remarks, and I'd like to go to two of the things you've said and ask you to expand a bit on them. I think you would likely have a perspective that maybe not everyone has.

"We see the sick and elderly having to rely on family members or community volunteers for care previously provided for them by trained professionals in safe environments." Could you be a little more specific about that particular statement?

Mr Reid: If you don't mind, if we have an opportunity, we both would like to respond on various issues.

The way I see that, being in the health care profession myself and being a professional who supplies health care in the community in London, I'm well aware of what's there for support services. When services are changed to go out from institutional care or from the acute care setting into expanding the community setting, the services aren't there. When elderly or people who need assistance with homemakers expect those services to be there to assist them in their daily life, there's a variance in the way services are provided. Those services may be employed by even the well-to-do, where they expect somebody to come in to supply those services and yet they come in to do the dishes or something else like this, which is not supplying home care.

Mrs O'Neill: Are you confident that Bill 173 will fix that all up?

Mr Reid: Yes.

Mrs O'Neill: You really do think it will.

Mr Reid: If we can look at and expand and ensure that the services are going to be there.

Mrs O'Neill: Without a financial commitment, it's going to be more difficult.

Mr Reid: Without the financial commitment.

Mrs O'Neill: And without the job security you're asking for.

Mr Reid: The way the system has been going so far is that there has been a downsizing of the systems in both the acute care and the community side of health care delivery, and that has happened basically on the backs of front-line workers.

Mrs O'Neill: Exactly.

Mr Reid: So it's been a downsizing of the system. The money has not been there, so it's been a downsizing of the system. When you downsize the system, then also therefore you're not supplying the services that are expected. You're leaving holes and you're leaving gaps and you're expecting that the majority of that work is going to be picked up by those who are left in the system in order to provide that care. As a front-line worker, we see this happening over and over, and when I say that, the stress that the workers feel is because they're getting stressed out with the fact that they're not able to supply that care that they once used to be able to supply because the time frame isn't there. They have that much more work that they have to perform in a certain period of time and they can't provide that quality of care that's there.

Mrs O'Neill: That's why I'm concerned about the expectations around this bill.

I just have one other area that I have time to ask you about. We hear this government talking about the community as though it was something warm and cosy that it just invented. There's been a lot of discussion about the word "community" even this morning. Would you like to say a little bit about how you feel that could be better placed in the bill or how communities could be involved as a result of Bill 173?

Ms Tracey Mussett: I think the first thing we want to say, and we said this last year when we came to speak about Bill 101, is that what's needed in terms of a community to support this bill is not necessarily what is really out there. I think that the funding mechanism that this system is going to use, based on a fixed number of dollars and not based on need, defeats the whole idea of a community planning for providing the service and then supporting the service, because if the funding is not based on need but the community is obligated to provide for the needs it's identified, you're not going to have a fit. You're going to have a community with huge gaps in service and I think that's where we end up with family and volunteers trying to provide service that there are not the dollars for. I think that if this bill is going to ensure an array of services, we need to see some assurance that that array of service is going to be funded to the level that the needs need. It needs to be funded to deliver a level and a quality of service that matches the needs that the communities have identified and planned for, and we don't see that.

Mrs O'Neill: Thank you for bringing reality to the discussion.

Mr Reid: If I may be permitted to give an example, when the government started looking at deinstitutionalizing the institutions where the adult mentally retarded were in, we started putting them out into the community, into the association of mentally retarded or group homes. The moneys weren't there. The government support and the assistance from the community was not there for those people. We ended up that a number of those people who were expecting and should have gotten that support from the community are now, a good portion of them, homeless and a good percentage of them are in correctional facilities because the community support was not there. We have concerns.

Mrs O'Neill: So do I.

Mr Reid: If we're setting up this type of thing in health care, are those services going to be there for those people when they need it? We don't want to see the same thing happen with this bill and this move to multi-service agencies and to a broader community health care or delivery system meeting the same kind of fate as what those people did that we gave them.

Mr Jim Wilson: Thank you for your presentation. A number of the points you raised have been raised by other presenters. In particular with the reform that's gone on over the past couple of years, things were supposed to get better, and you certainly get a feeling in my area of the province things didn't get better. We've had a reduction of real front-line workers also, providers. You're from London, Ontario. The government began this set of hearings again with telling us about all the money it's transferred from the institutional side, hospitals primarily, to community-based services. Can you give us a feel for how things are in your -- have things gotten better over the last couple of years?

Mr Reid: I would say that things are just starting to boil there. Being part of a committee that also sits on a district health council and with the restructuring aspect of health care delivery in the London area, we're just at the beginning process, but it will have, in a window time frame of some 18 months, probably a dramatic impact on the London area and the health care service delivery that goes on there. So it's very difficult to say at this time.


I know that there has been significant reduction in health care workers in that area. I know the attitudes and the feelings of people working in all the hospitals around that area and they're terrified. They're terrified for their jobs, they're terrified of what the health care system is going to be. There's no portability as far as their jobs go any more because the work market has shrunk so much, the dollars aren't there, and with the added increase in the workload, there are a lot more people who are being stressed and there's more sick time. It's a domino effect and when this happens, the quality of health care delivery definitely I think is deteriorating because I think we're putting too much on too few people.

Mr Jim Wilson: I just ask the question, I think it's a fair question, because the minister keeps telling us about upwards to 60% increase in some of the community-based budgets. If you look at the government's estimates, for example, there are several hundred millions of dollars taken off the institutional side that are supposedly being spent on the community-based side. Yet since I've travelled the province, I haven't been to any communities where things are actually improving.

I suspect a lot of the money, when you look at the fine print on the estimates, is just going into administration and new bureaucracies, and my worry is and what we've contended is -- and I'm wondering if you have the same worry -- that MSAs are just going to become another layer. I want to ask you particularly, because you're on the DHC in London and you guys are going through the regional stuff in London right now where there's always worry about, "Are we setting up another layer?" Specifically with MSAs, though, do you share the concern that a lot of people have told us, that it's just going to be another layer of bureaucracy?

Mr Reid: I think that's one of our fears, that it probably would be, that it has the potential of being so. Actually, what it should be and what it should represent is that it should break down the layers of bureaucracy, it should eliminate the number of boards that there are across the community for all the agencies. It should consolidate the administrative aspects of all community health delivery and be more focused on providing health care rather than the administration and the bureaucratic aspect of it.

Mr Jim Wilson: I appreciate your honest answer on this. At first glance, when you think you're going to be -- we're the party that did regional government originally in this province and we still can't get elected in those areas. Originally you were going to tear down some of these small administrations, and they do turn out to be fairly small administrations, and replace them with, in this case, the MSAs, the new regional government for health care, at least on the community-based side. History has shown that things don't get any cheaper or more efficient, that the "bigger is better" attitude doesn't hold out and that the bureaucracy actually gets bigger.

For instance, in Simcoe county we have seven groups and it's 97% non-profit, so it isn't one of these arguments about the private sector versus the non-profit sector. They have a lot of voluntary -- I mean "voluntary" in terms of the talk that goes back and forth, the communication between their groups, the referrals between groups that's going on now, and they can make a case that the seven of them, the VON and the Red Cross and that, are fairly efficient now. If I look at their administrative structures, they're not that large.

I have a feeling the MSA for Simcoe county -- because there may be more than one MSA in Simcoe county -- will end up having more bureaucracy than the seven little groups I have now. Is that good? It didn't turn out to be good for school boards, it didn't turn out to be good for regional government, and now we're doing it in health care. Have we not learned anything in 20 years in this province with these experiments? That's my question to you.

Mr Reid: It's a difficult question to answer because --

Mr Jim Wilson: Because some of these non-profit groups, agencies -- now I know that OPSEU might have a little concern about a lot of the work volunteers are doing and, in fact, are going to be encouraged to do more, I guess, under this bill, if they can get volunteers for an MSA -- they're really not that large. Some of my local VONs have an executive director, a couple of people who work in the office and a lot of front-line workers. The administration isn't that large. They could make an argument that the administration is just going to get bigger under an MSA.

Mr Reid: Yes.

Mr Jim Wilson: And then we won't save any money.

Ms Mussett: I think the idea of one agency in terms of improving accessibility and a coordinated approach is not something we have a difficulty with.

Mr Jim Wilson: No, neither do I. The original idea, though, it was going to be one-phone-number type of thing, one intake office.

Ms Mussett: That may still be the case in some communities, and I think a community is the best place to decide what, in fact, works for their community. There's such a diversity within urban communities, let alone the difference between urban and rural, and I think a community will decide that, yes, the buildings will stay the same but there'll be one phone number, if that's what suits them.

Regardless of whether it's an MSA design or a whatever design, the way they have been working through the process and what they call consultation and what they are saying is consumer need and what we're saying is dollar-driven is what the problem is. In the meantime, they're shifting a lot of the responsibility on to families.

In the brief we refer to the consumers asking to be allowed to stay at home, and to me "allow" means the choice to stay at home, not that that's the only place they can now receive service. Families will be allowed to care for their families, but I don't think there are families who would like the government to demand that they provide service that we say is a vital human health service.

The reality is that we're talking about women as family care givers, and I was one, and the reality is that a lot of women are now in the paid workforce and I don't know where the hours in the day are going to come from to provide that quality of service.

Again, we're not disputing that an MSA may be a good idea. What we're saying is that the process and some of the outcomes that we see, because of things that are missing in the bill and may well be covered off in the regulations, are things that have a direct impact on quality of care and quality of work.

Mr O'Connor: I appreciate you coming forward today. On looking through this brief, "The Rhetoric and the Reality," it certainly is a good name for it. I find it somewhat disappointing because quite often I have respected the union movement for approaching things in a more open fashion.

The reality is that if we take a look at the money put into the community by the present government -- in 1990-91, the community side, there was $550 million. This fiscal year, $850 million will be put in there. That's a 54% increase. That is a reality that I would hope maybe you'd recognize.

I don't know whether you're aware of the MSAs being given the responsibility to develop a human resources plan, a plan to take a look at the effects that they would have within their local communities. If you've got some suggestions how that might be accomplished, I'd appreciate that.

This morning we had some very interesting presentations, one by the Ontario Coalition of Senior Citizens' Organizations. They represented the consumer side and quite often when we've seen involvement at district health councils, for example, by local labour reps, they've been able to bring forward a different perspective as consumers of many services. I know this may be an area where you might have difficulty in representing some of the consumers' concerns.


I think the importance that they presented was that the see the benefit of a single access point. There's definitely a benefit. I know that as MPPs, when we go out and knock on a few doors to talk to some people, one woman I met last Thursday afternoon, who's slowly going blind, can take care of herself quite well but is going to have problems going to get groceries. Where does she fit into that system? She doesn't know, but if there's one access point -- the first part of the services she's going to need is going to be light, and they will become more demanding as she ages, no doubt, but that one access point for her is going to make a big difference.

I think that was the focus we heard this morning, and I hope that as we continue the hearings we're going to hear some of the focus towards the consumers, because the money is being put into the community. There's a real commitment by the government to put the dollars forward that are necessary. The focus here needs to be on the community, and I think there are very important roles that labour can play in approaching the needs of the community: direct involvement with the district health councils, membership on MSAs. But at the same time, let's try to keep a focus that the intention here is to bring forward some service that is important to the seniors, to the consumers, to somebody who is disabled, who needs to have that single access point.

Mr Reid: To answer some of your questions, first of all, we've always advocated the fact that as health care providers, we are the advocacy for the community, for consumers and for the communities that we live in, because we know. We deal with the people face to face.

You talk about, how would labour fit in with the human resources planning? To me, it seems rather ludicrous to in some degree start doing human resources planning on such a broad scale without involving labour's input, whether it be organized or whether it be unorganized. The people who are working in the field supplying the services definitely have a lot of input into how human resources planning should go, and they should be included in that process.

Probably one of the better ways of being able to do that is their involvement within district health councils, because the district health councils are the ones that are being charged with the responsibility, through the ministry, of developing the MSAs and also with all the other aspects of health care restructuring, and it's important that there is that labour perspective, that health care provider perspective, and also, by being that, as I said, they're also giving a community perspective, because we're not only providers, we're also consumers.

It balances out and gives a good balance as far as representation goes, because sitting on a number of different committees on district health councils, I can give you a fairly good insight as to who sits on district health councils, and it is probably, in the majority of the cases, the more well-to-do, well-established administrative people, company CEOs, the upper 4% or 5% of the community.

Now, sitting as a provider not up in that 5% of that community, I wouldn't say that is totally representative of the community as a whole. So to get that perspective from those people who are actually doing the work and who actually know what's going on and what is needed and talk to the people and talk to the community, then you're going to get a much more productive way of being able to go through this transition in the way we provide services.

Mr Malkowski: Thank you for your presentation. It's interesting to hear some of your feedback on the labour perspective. It's important to us and your words are important to us.

You mentioned employment security. I know that's an important perspective that we, as a government, do care about, so I'd like to direct my question to the parliamentary assistant to the minister and ask, the $850 million, the infusion of new funds that we've increased, what percentage of that will go in employment security and where is it balanced for some people as long-term care becomes a reality? I'd like your comments on how employment security will be achieved.

Mr Wessenger: With respect to the question of employment security, I understand the minister has indicated on several occasions that unless there's a human services plan in effect with respect to an MSA that provides for the fair dealing with the employee situation, the MSA will not be approved. That's, as I understand it, the mechanism of ensuring that there is a protection, a security provided to employees.

I must say, one of the aspects of the MSA is to try to divert more resources to front-line employees rather than to have as much spent on administration, so certainly one of the purposes of the MSA is to create more front-service positions. Also, if we look at the history, as I understand it, approximately 5,000 jobs have been created in the past in the long-term care area.

I don't know whether the policy adviser can add anything to what I've said.

Mr Quirt: Just specific to the member's question about the distribution of funding, there was $647 million committed to investment in the long-term care system; $206 million was invested in the budgets of the existing long-term care facilities; the remaining $157 million went into those budgets on July 1, 1993. On the community side, we've invested roughly $250 million of $441 million over the past three years, and we expect $200 million more to be invested in 1995-96 and 1996-97, the balance of the $647 million.

Mr Malkowski: A supplementary, if I might, to follow up on that point: Given that, what kind of guarantees would you look for and what guarantees should labour look for, in an MSA, on employment security? Could you talk a little bit about that, and from your own experience, as a union and a labour movement, what kinds of securities would you like to see built in, or how could we improve the legislation to satisfy you a bit more? What would you like to say to that?

Ms Mussett: I think the proposal that OPSEU, as an affiliate of the OFL with ONA and AAHPO, has been working on, an agreement that would be a more efficient and a more equitable way to approach labour adjustment province-wide.

I have a real problem with the MSAs being responsible for creating a human resources plan when we are saying to you today that labour does not have equitable representation on those committees that are doing the plan. I'm not sure if we are going to be partners with the ministry in reviewing those human resources plans as agencies apply to be MSAs, to help you decide that yes, that's a good human resources plan.


I think that the agreement we have been trying to work with the ministry on and, as I mentioned, we're including the employers in negotiating, that sort of thing helps set a framework for more mobility for workers. If a human resources plan limits workers to make employment adjustment within just the region of the MSA, I'm not sure that's enough employment security for people.

The ministry has said that the adjustments in the health sector, including the downsizing, should not lead to more unemployment, and we have been told that there will be more community jobs. But regardless of what the numbers say on paper, and I appreciate it when you say to me so many millions of dollars are going to the community, what we're saying to you today is that we are in the community, at the front lines, and those dollars are not making it through. I am still providing care to my family over and above what I personally am able to do and still maintain a quality of life that I think we assume is an entitlement for everybody in the province.

The rhetoric, if you're spending $500 million, $500 billion, what we're saying to you is, the system as it exists today has problems, and we're not trying to imply that that's been created recently, what we're saying is that a reality check has to be done, and let's look at what really is the picture out there. Then, if the MSA design is one that proves to be reasonable -- and again I would like to stress that we're not talking about a cheaper system; we're talking about a better system -- if the MSA design is one that seems feasible, then let's look at how it can be made accessible and how it can be made equitable and let's make sure that it provides the services to the needs of the people who have said they want access. Providing access and having no service is not going to do anybody any good.

We have a large retirees' division who are members of OCSCO, the group you referred to this morning, and we have determined that over most of the issues surrounding Bill 173 we are allies in our position. So we certainly have been listening to consumers ourselves, and that's how we've developed our opinions about a lot of this bill.

Mr Malkowski: Thank you very much for the feedback.


The Vice-Chair: The next presentation will be made by representatives of the Saint Elizabeth Visiting Nurses Staff Association. Welcome to the committee. Please introduce yourselves and proceed with your presentation.

Ms Laurie Clapperton: I am Laurie Clapperton from Saint Elizabeth's, and on my left is Heather Findlay, one of the nurses I work with, and Judy Franks.

I am pleased to appear before you today representing the Saint Elizabeth Visiting Nurses Staff Association. We have three nursing staff associations, one in each of Metro Toronto, Peel and Durham. The staff association at Saint Elizabeth's is made up of representatives who are employees who do not exercise any managerial or supervisory authority over other employees. These representatives are elected by their peers to promote and facilitate communication between staff and management and to promote a better understanding of the responsibility and concerns of staff and management. I am chairperson of the Metro staff association, but I am speaking on behalf of all three divisions.

I have been a nurse for eight years. For the first four years of my career I worked in a hospital, most of that time spent in the emergency department, but the last four I have worked with Saint Elizabeth's. The main reason I made this change was because hospital work was becoming increasingly removed from the real reason I had become a nurse in the first place. Hospital care is medically driven, and by its very nature and the hospital setting, it is difficult to address the psychological and social needs of clients. I wanted to work directly with clients in their homes, where this setting is more conducive to dealing with their overall needs. This type of approach is part of the philosophy of Saint Elizabeth's.

We work in people's homes, providing holistic care that includes giving treatments, teaching clients or their family members to administer some procedures, providing counselling and support and generally promoting good health. Our care helps to increase the independence of our clients and their families. These things are, for my colleagues and me, important elements of being a nurse and are vital components of the job we do.

Our biggest concern on an ongoing basis is the quality of care we are able to give our clients. Providing high-quality care which enables them to live more comfortable and independent lives, remain with their families and offers them choices is the driving force behind Saint Elizabeth's. This is the main reason we are concerned about Bill 173. We do not see how, under the new proposed structure, clients will be able to receive the same type of high-quality home care that we currently give them.

I would like to relate to you two examples of the type of care that we currently provide that is reflective of Saint Elizabeth's. I believe they show why the current system of having independent organizations such as Saint Elizabeth's should be maintained to ensure the continuance of high-quality care in Ontario.

The essence of community-based care is to be able to have the necessary health care services provided safely in the home so that the client is more comfortable, in familiar surroundings and given the necessary attention, not just by health care personnel but also by friends and family.

Recently, a client of mine died. She was faced with a terminal illness and was not being offered any treatment and she chose to stay at home, as many people wish to. My colleagues and I provided the nursing assistance that was necessary, helping to control her pain and teaching her family how to meet her personal needs. But more important was the fact that her friends and family, the people who loved her most in this life, were able to provide the care for her, making her feel loved and comfortable until the end.

This would not have been possible in a hospital, and in this case was only made possible because of the services provided by Saint Elizabeth's nurses. She was in her own bed, surrounded by all of her family, including her elderly husband, who would have found it difficult travelling to the hospital to visit her. This is the essence of dying with dignity, and I am not sure this type of care will be able to continue under the proposed system.

A second case is an ongoing one of a little boy trying to live a normal life. He requires a very expensive drug in order to live. Originally, he was going to a community clinic once every two weeks for treatment. Then new research showed that this drug could be as effective if it was administered more frequently but with a much lower dose. This would help ensure more balanced usage and decrease the total cost, as this is one of the most expensive drugs in the world. The problem was that for him to visit the clinic for this treatment would mean missing part of a school day twice a week.

This problem was solved when he was referred to us. I now go to his home after school and give him his treatments, by which time his mother has arrived home from work. The result is that he is able to have a normal school life, be more comfortable when receiving his treatments and is now learning to give them himself. Eventually my services will not be required. Had he been forced to attend the clinic, his life would have been disrupted and he would not be making the type of progress he currently is. This is the type of care that we should be trying to achieve and expand.

These two examples are common of the types of services Saint Elizabeth's nurses develop and provide on an ongoing basis. We are always striving to offer better, innovative and more flexible care based on the needs and choices of our clients. Under the proposed MSA structure, we see no guarantee that we will be able to continue to provide these types of services, nor that clients would even be able to choose us to provide any services. This does not signal improvements in the quality of long-term care to Ontarians.

The people who are the care givers are a key component to providing quality care. With the provisions contained in Bill 173, we do not believe that nurses will be either encouraged or motivated the way we are at Saint Elizabeth's.

All nurses are different. Not all want to provide specialized services, nor are all suited to working independently, which is a key requirement of my job.

It appears to us, particularly given the fact that MSAs will be self-contained within defined geographic boundaries, that the emphasis will be on all nurses providing all services. This is neither practical nor feasible. Many treatments require specialized training and constant usage in order to maintain a high level of skill which will ensure the most comfortable and safe treatment for the client. This is unlikely to happen if nurses are assigned to a relatively small geographic region and are expected to provide a multitude of services. The needs of the clients and the individuality of their situations must be taken into consideration and matched with the appropriate nurses to ensure the highest standard of care possible. How will MSAs be able to ensure this type of individual care exists?

As well, Saint Elizabeth's nurses are concerned that passage of this legislation will make all the members of my staff association employees of the MSA government structure. This is not a change which, with all due respect, we would support. Saint Elizabeth's sets very high standards for its nurses and the services we provide. The working environment energizes nurses and creates a significant degree of loyalty to the organization. The organization is very supportive of its nurses and has a very strong commitment to promoting and training nurses, if they desire.

For a nurse who wants to obtain education in a number of specialized areas, the opportunity is provided by way of paid education days and exchange programs with other providers. For a nurse who wants to provide basic nursing services, that desire is also supported. The opportunity for advancement exists and is based on qualifications and desire, not just seniority.

This is something we fear would be dramatically changed if we were forced to become MSA employees. If this change was to occur, we believe much of the motivation for being a nurse with Saint Elizabeth's would disappear and the quality of staff and their commitment would decline.


As well, as the needs of the community change, Saint Elizabeth's looks for new opportunities and new ways of providing services. In a general way, this can be seen by the changes that have taken place during our 86-year history. We have moved from providing home care for mothers and babies to giving a wide range of complex treatments. We seek out the needs of the communities we serve and try to develop new services which will address these needs.

A prime example is the home chemotherapy program we developed over three years ago, which is particularly helpful to people who have difficulty travelling. Clients are referred from hospitals or cancer clinics to home care, who then refer them to us. As specialized training was required to provide these treatments, two of us who are interested in this area were given intensive training. After the first year of providing the service on a test basis, the project was deemed successful and the decision made to continue it.

The service has grown to involve four specially trained nurses who are able to provide this therapy to the people who need it. The result is that individuals are no longer required to leave their homes and wait around in hospitals or clinics for their treatment. This service is not provided in the same comprehensive manner anywhere else in Ontario.

A second example is the Saint Elizabeth's mental health program. This program helps treat the psychiatric as well as the physical needs of clients. A team of mental health nurses provides the necessary care in the homes, with the result being that patients, clients, can remain in their homes longer and avoid hospitalization.

Services like this provide breakthroughs in terms of treating people, but in part are developed only because of the healthy competition which exists between health agencies. As in any type of service operation or business, the competition between agencies helps to generate new ideas, new treatments and, in the end, more choices and types of care for clients. This is a strength of our current system that must be maintained. We fear this environment will not exist with the introduction of MSAs.

While I have primarily raised the areas of Bill 173 with which we don't agree, there are sections of the bill which we support. These include the proposed patients' bill of rights and improved access to information on services. We commend the government for trying to make these changes.

However, the way to achieve these goals is not to create large organizations such as MSAs which are responsible for providing services as well as providing information. Health care services are just not that easy to dispense. Rather than continue down this road, we urge the government to consider changes to this policy that will allow easier access to the services without having to actually provide the services themselves.

Ms Carter: I feel as though what you're saying is kind of going parallel to what we're trying to do in this bill, but that because you're afraid somehow of the changes and how they may go, you're not seeing that.

I think most people in the province now don't have the opportunity to choose a Saint Elizabeth's nurse. The people who do are obviously lucky; you obviously have a very flexible and devoted service. But one of the government's concerns is that this kind of care is not available all over the province, and what we're trying to do in this bill is to make sure that the best of the services we have now are going to be available on a province-wide basis, so that somebody living in some rural area that's maybe not very well provided for will have the same essential services that somebody in Toronto might have.

Also, of course, we are emphasizing community care. You seem to be saying that perhaps people are going to be forced to stay in hospitals instead of being looked after in this more flexible way in the community. I don't feel that is the case.

Also, I don't think the disruption is going to be quite so drastic. There will be a coming together of organizations, but I don't think they're going to just be totally overturned, and of course there is a four-year time for the transition to take place.

Now, a question I have for you is, the basic change to the multiservice agency is happening at the local level, so the process won't be the same in each area because it is locally driven and concerned people in the area are working on these committees and forming the way that it's going to happen in their area. Are you people involved in that work in your areas? Are you taking part in the process so it will happen in the way that you feel is most beneficial?

Ms Clapperton: I'll do my best to answer your question. Certainly people within my organization have been very involved on different levels in the last two and a half years, and I guess the concern of ours here today is, again, the quality of care. What it comes down to is that we have been offering these services, and certainly Saint Elizabeth's has made every effort to expand the type of care into other areas. As a non-profit agency, it would certainly benefit the government to have contracts with Saint Elizabeth in other areas of Ontario. Those contracts have not come up to date in areas other than the Peel and Durham area as well as Metropolitan.

Again, coming back to the quality of care to the clients, certainly we'd love to be able to offer our services in other areas and have expanded up to York and into Kingston so that those services will be available to the clients and to the communities there. I'm not sure that I clearly answered your question.

Ms Carter: Of course, you did mention the bill of rights, and of course there'll also be plans of care for each individual consumer, so hopefully there will be that flexibility to make sure they will get the care that they need. Also, of course, and I think it has only been mentioned once in these discussions so far, the Advocacy Act is coming into force. That will give consumers, however frail or whatever they may be, the chance to make their opinions known, and if they aren't being treated in the way that they feel is ideal, they will have that channel of communication. So I think the consumer is going to be looked after. That's certainly what the intention is.

Of course, another point at issue is that you feel that it would be better if we had the one-stop access but then that the organizations delivering the care should be separate. The feeling I think in drafting this act was that by having both the assessment and the delivery within the same organization, you do get an increase in efficiency, you reduce costs, you have easier communications. Do you have any comment on that? Do you not see those as some plus factors?

Ms Clapperton: I would have a comment in regard to that, because, number one, with the MSA structure it is my understanding that the different services are going to be lumped together and, as such, the health care that's provided by the nurses in the community is a very unique type of service requiring a lot of education and, again, maintaining the skills of the nurses, because we work alone in the patients' homes and a lot of the things that we do would have a very detrimental effect on our clients if they were not done, carried out, in the appropriate manner by knowledgeable and skilled nurses.

Because our organization is a structure built on offering these health care services to our clients, as well as the organization, right up to our CEO, our RNs, who fully understand the needs of our clients as well as the educational needs of our nurses, by lumping all of the services together, what you're doing is combining them, where some people perhaps are not going to get the full services that are being offered now.

Yesterday I believe it was mentioned for the government to still be able to contract out to the different agencies for the work, if people are still getting the high-quality care in the home, and the services, and it's still being done by being able to contract out to the individual agencies that are already in the community and have been providing that care and providing it very well for over 85 years.


Mr McGuinty: Thank you for your presentation. I believe that the question we should be holding before ourselves here as members who sit on this committee is what is in the interests of the consumer at the end of the day, not what is in the interests of the various providers, with all due respect.

Of course, that's an important consideration, but at the end of the day, paramountcy has to be given to the interests of the consumers. You know, we've been talking about a bill of rights, and one has been drafted and inserted in the bill. It seems to me one of the rights I should have is the right to choose, and particularly, as an extension to that, the right to fire somebody. If I don't think they're doing the job for me, I would like to have the right to fire them and bring somebody else in, and my concern is that our consumers won't have that right.

I have every reason to believe that your organization, like many others, brings a high level of skill, degree, care and compassion to the work that you do. I have my own reasons for believing that there would be problems, but you tell me: Why could we not, as the government is proposing, transpose that work ethic to the MSA? Let's assume now you're all working for the MSA. Why could we not bring all of that work ethic to that new workplace?

Ms Clapperton: I think number one is, you can't transport the heart and soul of the organization into a government structure. That comes down to our values and our missions: caring, providing care and compassionate services to our clients and providing that in a flexible way; not only meeting the needs of the clients as far as their services, but also the times in which -- we do provide also 24-hour service to our clients. That is probably one of the main reasons why we can't transport it into a different, perhaps more government-structured, agency such as the MSA.

Second, we work as a team at Saint Elizabeth's. We are an agency where, as nurses, we've had a lot of input into how things are done at Saint Elizabeth's. We are the people who give the care. We are the ones who are in the homes seeing the patients. Patients talk to us and tell us what they need and how things will help them better. We are able to sit down with different managers in our agency and we're able to discuss those problems that we're having and give forth our ideas and our input in how to better service our clients.

The nurses at Saint Elizabeth's have a great deal of input. We're listened to, and a lot of the policies and procedures and the different ways that we work reflect that. I don't believe that does happen in government structures.

Mr Jim Wilson: Thank you for your presentation. As I'm listening to the questions here, I think they're a bit skewed. Perhaps the wrong angle's being taken here, because I don't think it's incumbent upon you to justify why the government should be having MSAs. You're already doing a good job providing services.

I think it's incumbent upon the government, which wants to not only have one-stop shopping in the terms of one point of access, which I think most people agree with. There would be a little bit more ease in local communities for consumers or clients or people, as we really should be calling them, to get access to these services. But the government tells us that during their consultations they heard that the public also wanted the MSAs to deliver these services, and that's where we differ with the government because we certainly didn't hear that. That seems to be a last-minute twist that the government brought in, and hence we have this legislation as it's written.

I'm going to ask the government, because Mrs Carter claimed it's going to be cheaper and more efficient to have a bunch of school boards or a bunch of regional governments out there delivering these services, because that's the way I picture MSAs -- I always compare it to the restructuring that's gone on under various governments on the municipal side, where somehow bigger is going to be better, and it turns out not to be that way -- I'm going to ask the parliamentary assistant, do you have any studies or any paperwork on this at all to present to this committee how and why MSAs are going to be cheaper and better value for the taxpayers and the consumers of this province?

Mr Wessenger: Well, I certainly could respond to the question, but since it's specific on the question of studies, I will ask the policy person here.

Mr Quirt: No, there had been no study done that costed the multiservice agency model in comparison to the brokerage model that was the original preferred direction of the government as reflected in its consultation document, that is, the service coordination agency.

The government, through the consultation, received specific advice from two notable groups, the Senior Citizens' Consumer Alliance for Long-Term Care Reform, representing a large percentage of seniors in Ontario, and the Ontario Community Support Association, representing over 500 home support agencies and a variety of other service providers. Both recommended that the shift away from the brokerage model and the giving of the responsibility to the agencies that deliver service to also decide who is eligible for how much was a more streamlined system and would result in administrative efficiencies, moving from over 1,000 agencies with administrative costs to many fewer multiservice agencies.

I think it's a stretch to compare the multiservice agencies to a regional government structure, given that there will be 15 or 20 in Metro Toronto. I think it's fairer to compare the multiservice agency to a variety of other charitable, not-for-profit corporations which are representative of their community and deliver a comprehensive range of services. Multiservice agencies' budgets will clearly be smaller than most hospitals and most children's aid societies and so on. So I think the notion of a large bureaucracy rivalling a regional government is perhaps not the best analogy to use for purposes of discussion here.

Mr Jim Wilson: Well, it is, because we went through committee hearings when they restructured Simcoe county recently, and they were taking 32 municipalities and making 16. You sell that to the public, and everyone thinks that's less bureaucracy, that's more efficient. Last year Simcoe county hit the first deficit in its 150-year history, $1.9 million. They're back at the government's door.

I voted against it, my party did, but they're back at the government's door now saying: "Jeez, that restructuring is awfully difficult. We now have oodles of road superintendents and oodles of all kinds of people around. We've got to remap the place and we've got to do all kinds of things that they didn't think of." So don't tell me bigger is better, because it hasn't worked. In fact, I thought the style of government in the 1990s and beyond was going to be smaller autonomous groups that would think for themselves and make decisions for their local communities, and that's not what these MSAs are turning out.

I guess what I say to our presenters is, do your consumers think there's something wrong with the services you're delivering and they're begging that you get out of the business and set up an MSA? You deal with real people, right, not just two groups, Dan Stapleton and Jane Leitch, who I think should be subpoenaed to come back here and tell us on what basis they made that recommendation.

I think Mr Stapleton is coming tomorrow, and remind me, please, committee, to ask him that question: On what basis did he convince the government that we should move to an MSA, not just one-point access but have the government now delivering the services?

Mr Wessenger: You can ask him that question.


Mr Jim Wilson: What's broken? Why are we going through this?

Ms Clapperton: Actually, I would be pleased to answer that. I think the biggest part of what I hear from patients and from what most of the nurses hear is that, number one, they actually are very pleased with the service and can't believe the things that are now being done in the home. But a lot of times people didn't know about it perhaps when they should have. They didn't know it was available. They didn't know until finally they were hospitalized and finally someone at the hospital realized that they might have a problem at home. They didn't know they could get this service or that it was available to them. I think that's a very big complaint that we've heard time and again.

Mr Jim Wilson: But that always occurs whether the government's running it or not. There could be a counterargument made that because there are a lot of agencies out there there's a lot of different contact, a lot of different fund-raising activities going on, so people know about the Red Cross and they know about the sisters and they know about -- the surface area of exposure now is quite large because there are a lot of groups out there doing their thing and coming into contact.

Having one MSA you might actually reduce the contact with the public. I can't picture MSAs being any more proactive than the myriad of groups that are out there now. There will always be people who go without services because they don't know about them. We know that through -- government has been in the past through multimillion-dollar ad campaigns and we find out our awareness is raised less than 1% or 0.5%. We see that in smoking campaigns all the time, TV ads and everything.

Maybe you'd agree. I can't see how the MSA is going to give them any more exposure; in fact, I think we get lots of exposure now with people coming into contact with them, mainly because of the fund-raising and volunteer activities. Think of the thousands and thousands of volunteers out there who are spreading the word about the organization or agency they volunteer for. MSA -- I don't think you're going to have that.

Ms Clapperton: Also the different programs that we do offer now, we've linked up with a lot of the different community hospitals to be able to offer a lot of the different programs such as the home chemo program or the mental health program. Certainly people have become more and more aware of it, even particularly in the last five years because of those programs.

The Vice-Chair: Mr Jackson, did you have one short, urgent question?

Mr Jackson: Very briefly, in the last six or seven years there have been some substantive campaigns put on by your broad sector of health and support workers for the elderly because of funding cutbacks and because of cuts to anticipated revenue and for expansion of services. During those campaigns you took some risks politicking, but it was fairly easy because you were advocating for your client and you weren't sort of in direct conflict with the government.

Could you tell me how you envisage your new world under Bill 173 where you're essentially an employee of the government, and now how do you go and advocate? Who will be the advocates for these people, the clients, if in fact the front-line workers have been fulfilling that important role? And I mean publicly criticizing any government that its funding levels are down.

Mr Wessenger: Mr Chairman, I think Mr Jackson is not being accurate when he states that the people are going to -- it's been clear that these are non-profit organizations, MSAs. They're not government-appointed directors, they're locally chosen. They're non-profit corporations, so I think it should be clear on the record that these are not government agencies. They are non-profit --

Mr Jackson: All government agencies are non-profit. I hate to break that big news to you.

Mr Wessenger: Well, no more than the --

Mr Jackson: It's in their nature not to make a profit, so if you think this is arm's length from government you're dreaming in Technicolor.

Mr Wessenger: It's the same -- the MSAs are --

Mr Jackson: The parliamentary assistant has a --

The Vice-Chair: One speaker at a time, please.

Mr Wessenger: Mr Jackson, the MSAs are no different than --

Mr Jackson: Mr Chair, was that a point of order that interrupted me? Was that a point of order?

The Vice-Chair: Yes.

Mr Wessenger: It was a point of order. Yes, it was a point of order.

Mr Jackson: A retroactive point of order.

The Vice-Chair: Thank you for your comment. Had you finished your question? We'll ask the witness to respond.

Mr Jackson: I had completed my question. It was the deputants who were interrupted, not me.

The Vice-Chair: Thank you. Yes, did you wish to respond to the point made by Mr Jackson?

Ms Clapperton: I will try to. A big part of what we do now is we deal with the home care program and we do advocate very strongly on behalf of our clients because they are, in essence, the managers of the purse-strings and each visit is paid for by the home care program as are the supplies and any accessory assistance in the home such as homemaking.

So many times, when we're speaking on the phone to the person in the office, we are having to explain why the client needs these things and explain ourselves and what our role is in there, and that in fact gets the clients the services they need. In that way, we very strongly advocate for them and if within the MSA structure I am an employee of that MSA structure who is providing all services, I believe we will lose some of that ability to advocate for our clients and for their individual rights.

Mr Jackson: You are now the person on the other end of the phone.

Ms Clapperton: Yes, saying, "I'm sorry, no."

Mr Jackson: Yes.

The Vice-Chair: Thank you for your response. Ms Sullivan, you had an even shorter question.

Mrs Sullivan: Yes. It's a comment with respect to what I think was a real attempt by the government to, I suppose, underestimate the magnitude or size and scale of the multi-service agencies. I think that when we are looking at community-based services which the minister herself has predicted that in less than a year and a half will cost the taxpayer of the province well over $1 billion, when we see neighbourhood agencies, such as Senior Link, which came in to appear before us today, discussing its local budget of $7 million, and when we see population bases that these MSAs will cover of about a quarter of a million people in most communities, this isn't small potatoes stuff. This is not the neighbourhood agency, this is not the community agency that many people have been mistakenly convinced is going to protect them and be their advocate and provide their services. This is big, broad stuff.

And while Mr Wilson has picked regional government as a comparative level, and it may not approximate regional government, it is certainly a similar style and the range of the process is comparable, even if perhaps the total value of services provided isn't quite the same. I think that nobody should kid anybody out there. This is big structure and that's not what I think those community consultations that you're so proud of ever contemplated.

The Vice-Chair: Thank you. Did you wish to comment briefly on that? Thank you for not commenting. Thank you for your presentation at this time.


The Vice-Chair: The next presentation will be made by the Ontario Palliative Care Association. We will limit our questions in future very, very much. Please take your seat, introduce yourselves and proceed with your presentation when you're ready. Welcome to the committee.

Mrs Shari Douglas: Thank you very much. I'm Shari Douglas and I'm president of the Ontario Palliative Care Association and a director of the national palliative care association. My colleague and copresenter is Mrs Connie Smith, and she'll follow my particular presentation.

The Ontario Palliative Care Association welcomes the opportunity to present its views with respect to Bill 173, the Long-Term Care Act. The association has been in existence for 10 years and is composed of a membership of over 400 individuals including nurses, physicians, volunteers, social workers, therapists and clergy who work in or have had experience in palliative care. The interdisciplinary nature of the association brings many perspectives on the care of the dying.

It is the belief of the association that palliative care should be accessible to all individuals faced with illness no longer responsive to curative treatment; considers the physical, spiritual and psychosocial dimensions of that person; provides support for the individuals and families facing death and bereavement; and is interdisciplinary in its nature.

The association is governed by an elected board of 12 directors and these directors come from 12 different regions of the province. We do have consumer representation and we also have cross-board appointments.

The Ontario Palliative Care Association's mission is to be a supportive forum for its members and to be a coherent voice for palliative care in Ontario. The goals include support to its members, and encouragement of the development and expansion of palliative care and services in this province. The association attempts to achieve these goals by providing education and developing opportunities, by facilitating communication and by acting as liaison between local, regional, provincial and national palliative care providers.

The association has welcomed the many opportunities to participate in the extensive public consultations. We have been very encouraged to see that the reform reflects the issues and concerns raised by this association. We have been very actively involved in the provincial palliative care initiatives, having representation on the working groups and on the steering committee. Our members are continuing to be involved at the regional level, planning palliative care education for physicians, community service providers and volunteers.

On behalf of the association, I wish to comment on several sections of the bill. I'd like to start with part II, "Interpretation."

Professional services: The inclusion of social work services and dietetic services as criteria services will now allow for greater flexibility in meeting the needs of palliative patients. As well, the enhanced funding package will add flexibility to better plan for these individuals.


The Ontario Palliative Care Association supports the bill of rights. Many of these rights form the foundation on which palliative care is built. The right to be treated with courtesy and respect, to promote autonomy, to allow for dignity and privacy, to recognize individuality and respect cultural, ethnic, spiritual, linguistic and regional differences are all fundamental to the provision of palliative care.

Part VI, "Multiservice Agencies," the limit on purchased services: This is an area of concern for OPCA. There will be members of our association who will be affected by this decision. Many of the private sector businesses were established because it was recognized that in several communities the services needed were not available to palliative patients and their families. Patients were not being given the opportunity to remain at home for their final days or to die at home.

These businesses recognized that our present system was lacking and filled the gap. They will suffer because of the 20% decision. Whether palliative patients and their families will suffer I think is an ongoing question.

With the enhanced service package, we will still not always be able to provide enough service to meet the needs of some palliative patients. If these small private agencies are forced out of business, will the consumer have the opportunity to purchase privately?

This brings another question: Will the MSAs sell their services privately? Patients and families with private insurance coverage frequently use this to top up the service packages provided. If purchasing from an MSA is not an option, continuity of care will compromised.

Part VII, "Rules Governing Approved Agencies," the development of a plan of service: Assessing the person's requirements, determining their eligibility, developing a plan of service, and revising that plan of service are all key elements to the successful management of a palliative case in the community.

Determining the palliative patient and family's needs, respecting their physical, psychosocial and spiritual needs, establishing a goal with them and a service plan to meet that goal requires skilful case management. It requires sensitivity to the patient and family's emotional state. Here we need to look at where the family is at with their illness, where they see themselves, not where we'd like them to be. Good grounding in palliative care education is essential.

The provision of palliative care in the community is both demanding and rewarding. It requires a team approach. Community service providers often work in isolation and case managers often are looked to for emotional support by members of this team. Skilled case management is the glue that holds the palliative care team and the community together.

Part VIII, "Rules Governing Service Providers," access to personal record: In regard to the person's right of access to their personal record, it has been clearly identified that transfer of information and access to medical records is often a barrier to the provision of palliative care. Palliative patients see many health care providers through the course of their illness and undergo many procedures and treatments. Repeating their story to each new provider they encounter is a great frustration and a burden.

A travelling chart that belongs to the client, with their own history and their own treatment plan, is currently being developed in several communities in Ontario. The information in this situation now belongs to the patient, and they choose whom they will share it with. This approach supports patient autonomy and control.

Part IX, the appeals process, application for review: There are two points to be raised in regard to the appeals process. With the present system of service provision in the community through home care programs, additional supports are not provided, for example, from insurance companies until home care has reached its maximum level of service.

It has been brought to the association's attention on a number of occasions that additional supportive programs would like to become involved, for example with AIDS patients, but, in accordance with their program guidelines, they must wait until home care provides a maximum level of service. They often wish to challenge home care service plans. They'll encourage the clients themselves to challenge this, and I wonder if there will be a mechanism to deal with this.

Also, as mentioned previously, there are problems with insurance companies. Approval of additional services to be paid for through insurance companies is becoming increasingly difficult to obtain, to the point where many patients die before approval is received. I wonder if there will be anywhere in the act where this will be addressed.

By having an appeals process in place, it is hoped that the provision of services for palliative patients will become more uniform across the province. In other words, I'm hoping that it will have a positive effect, because we've heard over and over again where there are variances within case management areas and variances within programs, and I hope by having the appeals process, we'll see a positive result.

Finally, I'd like to talk about respite and choice. There is concern within the field of palliative care that with the redirection and reform, palliative patients and families may be forced or pressured to care for their loved one at home without access to respite or designated beds. There are palliative patients who lack the supports needed to maintain them in the community. For these patients, there must be options.

In conclusion, the Ontario Palliative Care Association, representing a diverse group of people who provide hands-on care and support for patients who are terminally ill, supports the redirection of long-term care. We support the basic respect for human life and dignity through the provision of excellence in care for the whole person and his or her family as the end of life approaches. This time presents many challenges to the care providers and society to meet the myriad of psychosocial, spiritual and physical needs of these individuals. Society needs to rise to the challenge, and government can take a leading role to ensure that appropriate care is available to all those suffering the ravages of terminal illness.

I'd like to turn it over to Connie.

Mrs Connie Smith: Good afternoon. I'm Connie Smith, vice-president of the Ontario Palliative Care Association. In conjunction with my colleague, I would like to comment on several issues: one-stop access, community, continuum of care and volunteers. I do commend government for a policy on palliative care in December 1992 and the inclusion of this provision of care in long-term care redirection.

Mr Chairman and committee members, the Ontario Palliative Care Association, as you've heard, represents the hands-on providers of palliative care in Ontario. We believe palliative care is an essential part of long-term care. Bill 173 creates a framework for long-term care. The association played a key role in the provincial palliative care initiatives and our members continue to work through the implementation at the regional level.

Throughout this process, the consumer voice was clear that ease of access was a priority for persons in need of service. Therefore, it is without hesitation that we support the concept of one-stop access.

Bill 173 is addressing community long-term care, excluding institutions, which suggests legislators and policymakers do not have a clear vision on the continuum of care. Consumers and providers alike define community and home as, "Home is where the patient currently resides." We must address the concerns regarding patient-client choice and the need for respite care. There is a growing concern that patients, clients and their families will be pressured, if not coerced, into providing care to the terminally ill at home. With shorter hospital stays and the nature of acute care facilities, it is clear beds will be limited. We believe long-term care facilities, including chronic care beds, have an important role to play in the provision of palliative care. There are palliative patients and clients who choose institutionalized care for a variety of reasons, and this must remain an option.

Let us look at a small Ontario community's experience in palliative care to date. This model is providing excellence in palliative care to the community residents. The home care provider contracts in-home services for patients and clients in the community based on client-centred care planning. The case manager is a member of the hospital palliative care team. Volunteers coordinated by the hospital provide support to patients and their families in hospitals, long-term care facilities and homes. The palliative care team provides 24-hour-a-day, seven-day-a-week available expertise to hospital staff, long-term care facilities, patients, physicians and community agencies. Respite and admission to chronic beds are available to patients and families as required. Can we be assured this choice will remain?

We must ensure Bill 173 does not deny any community to respond in an innovative way to meet the challenges of palliative patients and their families. We must foster and encourage the volunteer members of palliative care teams, because they are the link that reflects the dying person. The bill of rights must be the foundation for the vision of long-term care and its future direction.

In conclusion, the association supports the redirection of long-term care in ensuring patient/client-centred care for the terminally ill.


Mr Wessenger: Thank you very much for your presentation. I certainly appreciate it, and certainly some items have been raised that haven't really been raised before. Perhaps we could explore some of these recommendations.

First of all, you raised the question of the MSA selling its services privately. You indicate you wish to see that power to be there, and I can indicate to you that the legislation does permit that, but do you see any downside to an MSA providing services privately?

Mrs Douglas: If I can respond to that one, if MSAs don't provide the service, then it doesn't leave individuals who want to top up what their service plan is, to expand -- they're not going to have continuity of care. You're going to bring someone from a private agency into the situation where they're already used to the service providers who are in. You will lose your continuity of care. I see it as a positive move, so that they can expand on the service plan given to them.

Mr Wessenger: And you don't see any negative impacts?

Mrs Douglas: No.

Mr Wessenger: The other point you raise is the whole question with respect to the right of access to medical records. As you know, it's provided in the bill that the person will have a right to the information with respect to their own medical information. But I'm wondering, do you feel this right to access should be expanded, for instance, to allow the sharing of information between the providers without the necessity of going back to the consumer for their specific consent?

Mrs Smith: I think the association has addressed that in what we see as some pilot projects in the travelling chart, and I think as long as we give ownership to the client or their designate, then in fact they're free to share that with anyone they choose. But we certainly don't look to one consent and information-sharing across the board without really informing clients.

Mr Wessenger: Yes. Could you perhaps give a little elaboration about this travelling chart, some more information? I'm sure members of the committee would appreciate a little more detail on that, where it exists and how it works.

Mrs Douglas: I'm actually sitting on a committee now that's developing a travelling chart and I'm also on the provincial cancer network and sitting on the supportive working group where this idea keeps coming up over and over again, but it has over the last several years.

An example of an individual who needed such a thing as a travelling chart was an oncology patient who came to my area on holidays for two weeks, didn't have a physician in our particular region, got into difficulties with bleeding and needed to go to hospital. Now, what kind of records does she have? How do you ship her off to the local hospital and say to the physician: "Here you are. We've accepted the responsibility for care of this patient in our community, but we really don't know a whole lot about her." She, very nicely, had a travelling chart from the oncology clinic in her purse. So she was able to present that to him, which gave him information as to whom he should phone, what clinic she was attending, what treatments she had already had, what x-rays she'd had. He called the clinic and was able to speak with the oncologist and they told him immediately what to do, and the patient was treated, released from hospital the next day and returned to her vacation in our particular area. That's the kind of information we're looking at having patients have access to, so they can then take the information to people they want to share it with.

When you get into sharing all this information between agencies and between volunteer organizations, the mechanism of doing so and the barriers become insurmountable. So if the patient owns it, the patient loans it, and that's the way it goes.

Mr Wessenger: So you think that's the best way of dealing with the information?

Mrs Douglas: Well, it's a way around a whole lot of roadblocks.

Mrs Smith: I think our consumers tell us over and over again that -- certainly, palliative patients find that one of the most distressing things they're faced with is telling their story time and time again to care providers. If we truly are listening to our consumers, we have to look at innovative ways to meet that need.

Mr Wessenger: Right. Thank you. I appreciate that.

Mrs Sullivan: I'm going to follow on that same point with respect to the records. My sense is that the travelling chart isn't in fact the full medical record, and so there's a little bit of a difference here from what, by example, we were discussing with the consent to treatment bill provisions.

The diabetes association, I believe, has introduced a travelling chart --

Mrs Douglas: Right.

Mrs Sullivan: -- which is highly effective in providing coverage, and once again the patient has the control over sharing the information. One of the things I would caution about and that I wonder if counsel would look at are the provisions in the bill of rights with respect to medical records.

In the Consent to Treatment Act we took into account some highly professional testimony which indicated that for some people at certain times, access to their own records can cause a setback in the course of their treatment and their response to care. I'm just not certain if those provisions have been adequately transferred into the bill of rights as it's proposed in this legislation, and I think counsel should have a look at that. I think your idea of the travelling chart probably doesn't need legislation; it simply needs the will to put it into practice.

Mr Jim Wilson: Thank you for your presentation. I too had circled some of the stuff that Mr Wessenger already covered with respect to MSAs; for example, providing private services. I hadn't thought of that one either. If there are no private sector agencies around --

Interjection: What are you going to do?

Mr Jim Wilson: -- and there's no public sector or non-profit agencies around, it all comes down to the MSA having to provide it. It's something we'll certainly have to look after, although I don't see anything prohibiting that in the act. I think that was Mr Wessenger's point, but as with all points that are given to us, we will double-check that.

You've a very good sentence here that talks about "There are palliative patients/clients who choose institutional care for a variety of reasons and this must be an option." I'm a little surprised at your fairly strong support of this bill. If you take this bill with its companion legislation, Bill 101, if you look at Bill 101 and all the criteria that must be met to get into an institution, to get into a nursing home -- and remember, there's a bunch of new criteria and hoops that have to be jumped through before you're even considered to be on the waiting list to get into an institution -- one of those is that all other options have to be explored in your geographical area, so I assume within the MSA.

I think one of the problems with this bill and it may be putting out a bit of false hope, but I hope I'm wrong, is that the bill talks about these baskets of services that are going to be available, but because we don't know what kind of dollars this is backed up with, it may be that the government will deem in your area of the province that people can't go into nursing homes, because when they try and get to that "all other options criterion," they look and they've got an MSA and the government looks at its books and says, "That MSA has all of these things available."

I guess what I'm trying to say is that the two bills working together make it extremely difficult, I think, for someone who may choose, for whatever reasons, to want to be in an institution. The whole thrust of this thing is to keep people in their own homes. I can tell you that in my area of the province -- I remember when the government went around with its road show on the consultations on redirection of long-term care, and I told this story last year -- at the Simcoe Manor in Beeton, for instance, I had two ladies come up to me after they had witnessed the dog-and-pony show and say, "My God, does that mean we have to move out of this place and go back home?" They didn't meet any of the criteria. They were fairly well individuals, on the surface anyway. I said, "No, I don't think so." They said, "Good, we've peeled enough damned potatoes."

They were just perfectly happy being in the Beeton manor. That's where you want to go in my area; it's tender, loving care. I should say that because my aunt is the head of nursing there. We have palliative care teams and it's a wonderful place and it's where you expect to go, but you can't get in any more. If you go to the letter of the law when this comes in, it's going to be very difficult to get in, because the government's going to say, "Those services are available in your area, Mr Wilson, and I suggest your constituents use those services."

Mrs Smith: I think I can speak with some clarity to that issue. I also discharge-plan at a small community hospital. I think we have just seen placement coordination service come into our area. So far I see some very standardized assessment tools being used and I see that as positive. I think there are other alternatives, as far as institutions, as nursing homes are concerned. I think nursing homes and chronic beds provide a higher level of care and a level of technical expertise that may be necessary for palliative patients. But generally speaking, I think if folks don't meet those criteria, there are other institutions that are available to them, lodge settings and that. I simply don't think our system can support folks in high-cost facilities unless they need the service.

I certainly, from a discharge planning point of view and an institution bias, support standardized assessment tools and feel that folks need to be where the level of service can be maintained.



The Vice-Chair: The next presentation will be made by representatives of Victoria County Community Care. Please introduce yourselves and proceed with your presentation. Welcome to the committee. We apologize for the lateness of the hour, but you'll see the keenness the members have for this particular bill.

Mrs Val Barkey: We appreciate the opportunity to be before you here today. I'd like to introduce to you Peggy Long who's the chair of Victoria County Community Care, and I'm Val Barkey, the executive director of our agency.

I believe most of you have before you a script that we'd like to utilize; however, we'd be pleased, if any of you would like to stop us at a particular juncture, to do so. Obviously, there has been a planned format for questions, but I certainly invite that as I go through the presentation. I won't read it in its entirety, so if you think I've skipped a spot, yes, I have, but intentionally to hopefully address the issue of brevity.

Victoria County Community Care is a community-support service agency which has been providing a range of services for the past 10 years to seniors and people with special needs. Approximately 55 administrative and service staff and 400 volunteers combine their talents and expertise to improve the health and quality of life for Victoria county residents.

This represents nearly 48,000 hours of volunteer time, contributed last year alone. Peg Long, accompanying me here, was a major contributor to that total volume of hours. I know she'd be please to respond to any questions you might have with regard to voluntarism.

After so many years of contemplated reform, I'm sure we're all pleased to see the recommendations formalized in draft legislation. We must resist the urge, however, to speed to a conclusion without a sure sense that the proposed legislation will indeed create a preferred world. Essential elements in that preferred world are:

-- Reduction in the number of agencies and workers providing service to an individual client achieved through the integration of case management and service provision and the merger of agencies.

-- Single source for information and assessment services.

-- Adequate, flexible funding.

There are, of course, additional important elements as well and these include:

-- Much greater integration of housing and recreational initiatives with health and community support services. Seniors' needs will only be met if there is a continuum of service available, from recreation and leisure needs of healthy, active seniors to the heavy care needs of the frail elderly. Commitment to real collaboration and a continuum of service delivery begins with leadership and tangible action from Queen's Park.

-- Enhanced care giver support program development based on a greatly restrained reliance on families as care givers.

-- Continued collaborative involvement of client and community in the design and implementation of needs sensitive services.

-- Quality management systems.

Clearly, the greatest concern has surfaced over the issue of implementation. What needs to be done is always easier to describe than the how. The following is Community Care's response to Bill 173:

To purpose 1(a), we say: The government cannot ensure that many services dependent on volunteers will be available in rural areas.

To purpose (b), we say: How will the act improve quality? As a result of standards? Quality care is not merely a result of achieving standards. Integral to quality health services is a caring, compassionate attitude. The positive effects of soft, qualitative contributors on the healing process are well documented. Legislators must remember that conformance to standards does not necessarily result in healthy bodies or minds.

To purpose (c), our agency responds: To recognize the importance of a person's needs and preferences is clearly a worthy goal, but may we remind funders that the creation of site-specific care plans requires time and the commitment of funds to support this process. If the government is not going to increase funds for service planning and coordination which is sensitive to client preferences, then don't include 1(c).

To purpose (d), we say: amen, but do stop at the provision of the framework. Allow communities the ability to develop within defined parameters a system which responds to local need.

To purpose (e), we say: Legislators are wise to recognize that their responsibility is the promotion of equitable access to services and thereby achieve at least a modicum of justice. However, I sound a cautionary note. Having been involved in the development and delivery of community-based services in Victoria county for 10 years, I am convinced that the strength of this sector has been its ability to respond to need when rules and regulations of the traditional health care system failed.

Whether trying to coordinate ongoing transportation for a dialysis client or respond to issues of elder abuse, community-based services have been able to meet need because they were willing to go beyond the health care units, which often maintained that such needs were not within their mandate. Furthermore, I challenge legislators to recognize that access in rural areas goes beyond eligibility criteria and uniform rules and procedures. An infrastructure must be developed which recognizes the unique requirements of rurality and minimizes nature's access inhibitors.

Primary focus must be given to the issue of transportation, minimally addressed in part XI, section 51 of Bill 173. Rivalry between the ministries of Transportation, Community and Social Services, and perhaps latterly now long-term care reform, over mandates must be laid to rest. Local municipalities simply cannot be vested with the total authority to determine whether transportation for their citizens will be provided. In rural areas, where distance increases transportation costs, there must be a funding formula which neutralizes this factor if the government is committed to the concept of equitable access.

This is of significant import for so many programs. As we urge focusing on the general issue of nurturing a requisite infrastructure to support long-term care reform, and specifically on transportation, may we also encourage continued review of the misuse of ambulances for non-emergency transfer or physician appointments of clients in long-term care facilities. The Swimmer report of 1991 on emergency medical services must be considered when addressing the issue of reform and the provision of a continuum of services.

To purpose (f), we say: Who can argue with this purpose? Certainly not community care. However, there must be thorough and careful thought given to the measurement of efficiency. Agencies such as community care would welcome the input of those who could assist us to increase efficiency. However, when we still spend so much time trying to get volunteers to provide daily secretary-receptionist support or to carry out fund-raising, the issue of efficiency becomes academic.

A difficulty when measuring efficiency results from the significant variation of inputs. For example, to coordinate and arrange friendly visiting services for a client takes significantly more time than coordinating or arranging for Meals on Wheels service. If we measured the efficiency of an agency by units of service outputs, there may be a tendency to provide only those quick-fix, high-volume services because of the positive effect on the bottom line. There must be a heightened commitment by government to develop appropriate funding formulae if purpose 1(f) is to be fairly achieved.

To purpose (g), we say again, like purpose (f): The intent is laudable and necessary. Clearly, these are requisite functions in a reformed world. Perhaps the operative word is "encourage." The dictionary defines "encourage" as "to assist, to hearten, to inspire, to stimulate, to foster." Therefore, the purpose of this act is to positively nurture the listed functions.

May we indicate that no amount of legislation will inspire or stimulate unless it is developed with the recognition of the investment in human resources that these functions will require. If there is an expectation that community-based agencies and volunteers will continue to meet service demands while at the same time undertake these human resource consuming functions, we can anticipate failure. Collaborative planning and integration assistance will require a further human resource commitment. It cannot come from existing staff. Nor can we continue from one stop-gap employment grant to the next. There must be a tangible commitment of human resources to achieve the ideology of purpose 1(g).


Perhaps we could proceed now to the definitions. Generally, the definitions are clear. Predictably, though, there is still some concern over what constitutes an agency and whether the definition excludes a federated system in favour of a formal, legally created new entity. Perhaps greater concern resides with the implementation of the new definitions. Certainly an adjustment period for the education of both the public and staff will be necessary. Furthermore, if, as anticipated, the definitions are used to determine eligibility for funding, it is of utmost importance that the legislators consider the procedural or implementation challenges resulting from the definitions.

Also, our agency registers concerns that there is no clarification regarding supportive housing and attendant care services as components within the designated service pockets. Fragmentation will continue to be perpetuated until these services are considered within the context of the whole long-term care reform initiative.

Proceeding to part III, bill of rights, this part demonstrates a sensitivity to a broad variety of needs and yet one harbours a concern in terms of its application in rural areas. What is meant by the word "ensure"? Does it mean in rural Ontario, if our agency receives a request for a friendly visitor of a specific ethnic nationality, that it would have to ensure an ability to find a friendly visitor to match the request? Again, I suggest judicious use of the word "ensure" as it relates to rural Ontario and to those services provided by volunteers.

Part IV, dealing with directors and program supervisors' appointment, we respond: Historically, the word "appointment" has elicited both positive and negative responses. An appointment based on merit, free from partisan politics, is indeed an honour. Regretfully, though, we are all too familiar with appointments based not on merit but on patronage. If we value accountability and effective resource utilization, the yoke of patronage appointments must be lifted.

Part V, dealing with funding approvals: We suggest there is good flexibility demonstrated here. We question, however, the comfort level of volunteers who under section (a) could potentially work directly for a minister. A key concept in the management of volunteers is recognizing the satisfaction derived from making a positive difference in their local communities. Even though volunteers derive intrinsic satisfaction from service, funds must be invested for recruitment, training, scheduling, supervising and recognition as well as for expense reimbursement.

Regarding subsection 8(2), the agency applauds its inclusion. This clause is particularly important in rural areas where satelliting of local offices has proven a very effective method for service delivery. Continued advances in electronic technologies make the inclusion of this section even more appropriate and necessary.

Part VI, dealing with the multiservice agencies: As we all know, this is where the storm seems to reside. We acknowledge with appreciation the many hours of thought and study that have preceded the formulation of legislation governing the multiservice agency. We have responded with many others and we feel in terms of our perspective the following are the non-negotiables:

-- Flexibility with regard to the geographic area served based on genuine community input, not driven just by the traditionally strong health sector.

-- A full continuum of services must be available. Therefore, we suggest the exclusion that is allowed for in section 15 be eliminated.

-- Full public disclosure regarding the decision-making process for the selection of the MSA, particularly if a health unit or municipality is selected. The minister must be held fully accountable if either of the above options is selected.

-- Comprehensive information and referral. This service has traditionally been a funded home support service and we've witnessed its exponential growth in our county and we certainly feel this is one of the very essential elements that an MSA can offer. We've been able to produce as well as providing our 1-800 number some service directories which we offer to show you today and these have provided a very valuable service. So we certainly support strongly the recognition that information and referral must be enhanced.

May we again emphasize that if legislation does not merge community support with personal-support professional providers, the government essentially will have maintained the existing status quo or perhaps have exacerbated it. A potential wedge may be driven within agencies which offer personal support and homemaking services as well as a range of community support services. Energies must focus on achieving the goal of reduced service fragmentation while maximizing client access.

Part VII, rules governing approved agencies: It's generally straightforward here and listed by sections. Perhaps, though, we will just underscore some difficulties. I'll draw your attention to section 23. This clause will render section 21 virtually impossible to achieve. I'm sure you're familiar by now with the bill, but you might find it useful to refer back. I refer to the impossibility of providing written notice to a client for every service provided, which is currently proposed in the legislation.

May I illustrate with the provision of transportation services in rural areas. Client A might call the MSA to arrange a ride in a locale 20 kilometres away. The volunteer proximate to the client is contacted and a ride arranged. Now, how will that client be given the notice? Obviously, you cannot ask a volunteer to pick up the notice, or should you automatically allow the volunteer to carry blank forms with them in the car? If the computerized system is in place, this can present difficulties in returning the form back to base.

So often a service is needed and time does not permit delivering written notice of service. Last year we provided almost 100,000 units of service. If notices had to be given to all those clients, I'm sure we'd still be inundated and probably not even a third of the way through. That's not to reflect inefficiency on our part but just to indicate how much administration would be required if that clause were in effect. We urge the government to demonstrate common sense and a respect for practicality.

Section 24: Community Care is pleased to see the inclusion of this clause. Over the past 18 months, our agency has piloted the development of a continuous quality improvement program for our sector. This manual is the culmination of that project, entitled Integrating Quality Within Your Organization. Our agency is certainly committed to this concept, and it was demonstrated in our distribution of it to our members in the community support sector. We're not afraid of being required to operate and to demonstrate quality.

With regard to 25, despite the brevity of this clause, the issue of client contribution for service has been the subject of lengthy debate and wide polarity of thought. It has been our agency's experience that most clients are willing to contribute towards service provision. You may be interested to read of Community Care's experience with the provision of respite care. I won't read it for you, but it was an interesting experiment, and we certainly support the fact that service can be offered on a fee-for-service basis. Given our country's current economic malaise, we may look more intensely at cost-sharing arrangements for service provision.

Part VIII, rules governing service providers: Community Care recognizes the necessity to allow for the provision of purchase-of-service agreements. However, there is concern with regard to the increased costs inherent with purchase-of-service agreements and with regard to the establishment of fair and appropriate rates for the purchase of service.

There's an illustration there of the significant variation in input costs and how difficult it is to establish what is a fair rate, particularly in rural areas, when the factor of transportation must be addressed.

Generally, we would discourage the practice of purchase of service as much as possible so that a continuum of services can be provided under a global budget by one agency. Research tends to support this approach. There have been two good studies done, one by Rick Zawadski and Catherine Eng in their paper Case Management in Capitated Long-Term Care, 1988. They cite the finding that the "consolidated model actually proved less costly when the additional communication costs associated with service planning reimbursement and client monitoring were considered." Catherine Hennessy also addressed this issue in her paper, Modelling Case-Management Decision-Making in a Consolidated Long-Term Care Program, 1993. She provides a very interesting assessment of case management decision-making. It was found that generally the range of case managers had a "conservative approach to care planning. The most expensive and intensive plans were used sparingly." Balance represented by a good cross-section of health and social services may reduce the frequent knee-jerk reaction for a quick health fix.

It might be prudent to stop now and invite questions from you, if you'd like. The remaining parts can be read by yourselves, if you so desire.


Mr Jim Wilson: I would just like to tell the presenters that Chris Hodgson has used you as an example in our caucus on several occasions of how things could and should be done. In fact, although I'm Health critic, I think Chris would like to be Health critic because he's had a lot of experience on health boards and with district health councils and with groups such as yours.

I do have a question, though, on page 22 where you're talking about purchase of services. Perhaps it's the time of day or something, but it seems to me that your argument is that it's better to do these things -- I'm not sure what your argument is on pages 21 to 22 with respect to purchases of service.

Mrs Barkey: It's a good thing I didn't become a lawyer, isn't it? My clients might be in trouble.

Mr Jim Wilson: Do you want to make the point? While you talk about the cost of Meals on Wheels, I guess you're saying that some of the larger players are able to get a lower per-unit cost.

Mrs Barkey: What I'm trying to say is that inherent to purchase-of-service agreements is a significant amount of administration, which results from a complete separation of the contractor to the service provider, so you have to follow requests with a significant amount of paperwork, contractual work, and usually -- I know home care has to have lawyers review the service contract with other organizations. What we witness is that when home care, which is usually the purchaser of service, would purchase a service, there are these inherent costs that agencies have to absorb -- home care probably has to absorb some as well -- and they tend to augment the cost of service provision.

To introduce the other part of the equation, though, the cost charged for a unit of service doesn't always necessarily reflect the cost. That's why I give the example that for us a Meals on Wheels might cost in one area $10 and in another $4, but we get $5.25, so where does the other money come from: my fund-raising volunteers? Or how can we supplement that? And I suggest there are other hidden costs that still haven't been factored into that actual unit cost.

Mr Jim Wilson: How I thought that might roll into 173 is that I think -- and I might be wrong -- the government wants to set rates, particularly the rates that will be charged to consumers directly, the user fees. For example, there was a suggestion by Dr Greengarten from Baycrest that they would like some flexibility in their own area to not see a standard rate for services across the province but to be able to set different rates.

What I got out of that and what you've said -- I mean, your costs in a rural area may be higher than downtown Toronto to provide Meals on Wheels, and if the government sets a flat rate of $7 or something per meal, that may not actually cover your cost. Is that a concern there? There is the request before the committee to try and introduce some flexibility in the language of the bill so that local MSAs can perhaps set their own rates and their own charges to consumers.

Mrs Barkey: I think your summary is quite accurate and appropriate. Throughout our response, we've tended to use the words "flexibility," "framework," those words that do allow for a community to plan. While I recognize that sometimes that might be interpreted as inconsistency, we have to recognize that there are significant variations, from our perspective particularly brought about by rurality, that we must allow for in the funding formula.

Mr Jim Wilson: With all the discussion going on in Victoria county, do you have a good idea of what the MSA is going to look like? And how does Community Care fit into the new model? You're actually on the leading edge of some things. I'm just wondering how you're coming along with your MSA.

Ms Peggy Long: Very slowly. I don't feel that we really do.

Mr Jim Wilson: You don't feel you really do fit in?

Ms Long: I hope we would fit in, but I'm on the planning committee and I feel it's very slow and there's a variation of ideas as to what an MSA will look like.

Mr Jim Wilson: So you don't know any more in Victoria county than we know here.

Mrs Barkey: Again, we really would appreciate if we could have flexibility, from a significant amount of connections electronically to a full merger. There has to be some happy consensus, maybe some way in between. Our palliative care Saint Elizabeth persons talked about those really strong feelings of community that are attached to many of these agencies, and we don't want to be unmindful of those. But I think there's much we can explore to prevent some of the fragmentation that exists now. Just electronically we can do a lot to improve the way we do business.

Ms Carter: I'm not the member for Victoria-Haliburton -- of course that's Chris Hodgson -- but I am next door in Peterborough, and I believe as far as health services go there's quite a lot of overlap, so I certainly feel this is kind of home. Apparently Chris Hodgson used you as an example of how things could and should be done, and I think that's wonderful because I feel the same way. I would go a little further and say you're almost a preview of the kind of thing we're getting into with this legislation, because you are a county-wide organization, formed, I believe, from the amalgamation of several fragmented community support providers. Yet the fears we've heard expressed here about caring disappearing when we get this kind of amalgamation, that this flexibility, this concern for the individual consumer would disappear, doesn't seem to have happened in your case; in fact you seem to be a shining example of that.

Also, you still manage to attract volunteers. We're told that once we lose the ethnic or religious or whatever it is specific organization, volunteers are going to lose interest and they're not going to want to serve any more. How do you have such success in attracting volunteers?

Mrs Barkey: I'm not sure if we owe our good start to Geoff Quirt, who was my first program supervisor, but nevertheless we do consider the fact that in a microcosm, we do demonstrate a small MSA. We range from professional services, we have nurses working for us, health care aides, and we have volunteers. I think it results from being able to skilfully use people where they fit best.

Peggy, as a volunteer, if I can use her as an example, has a wealth of talents, which have ranged from producing our newsletter to chairing to being an outstanding support in the development of a rather unique program, our in-home respite care unit, a converted apartment unit which now provides seven-days-a-week respite care. Those sorts of things are a demonstration, I think. When you match people with their areas of skill and expertise, it's phenomenal what can happen.

I do harbour a concern, if there is strong unionization, that some of the ability to utilize volunteers in areas might be diminished, so I would hope that an MSA will never be a place where we cannot have the full opportunity to utilize volunteer skills.

Ms Carter: That's our intention too.

I think it's fascinating too that you're saying that the practice of providing services under a global budget by one agency is efficient. We've been sitting here saying that, and we've had so many presenters who have been contradicting that and saying that to have one agency coordinating and assessing people and then giving out the services to contract service providers is just as efficient. We're saying there are gains by having it all together in one organization, and you have very positively shown that it works in practice and that it is the case.

Mrs Barkey: The key thing is that it works for the client. At least two calls a day we would get from clients who are confused because they don't know which agency they should contact. Admittedly, with our name being Community Care it is somewhat confusing with home care, but if we work from that point of view for the clients, that they know one coordinator is looking after it, whether it's transportation, whether it's the respite care they need or whether it's the Meals on Wheels program, that person does in fact have a comprehensive knowledge of their needs and can dispatch either volunteers or paid staff to be a part of that. It's worked for us. I'm not suggesting that we know it will work for everybody, but certainly in our county we've seen that that ability to have a continuum within our own structure works.


Mrs Sullivan: There are a couple of things I wanted to raise. The first is a question of the parliamentary assistant with respect to the government's intentions re attendant care. Yours is the second brief that has raised the issue of attendant care and supportive housing. I understand why supportive housing is not included in this bill, but the attendant care issue is one that -- I would just like confirmation that attendant care would be covered under personal support services under routine personal activities of living and assisting a person with those activities.

Mr Wessenger: Yes, you are correct.

Mrs Sullivan: So we can pass on to organizations that attendant care is in fact covered by the bill.

Mr Wessenger: Mr Quirt would like to add something.

Mr Quirt: If I might just add a clarification, as a result of concerns expressed by the community of people with physical disabilities during our consultation, we've offered each group of clients from each attendant care outreach program we fund separately the option of, community by community, deciding whether they'd like to see their attendant care outreach services delivered by the multiservice agency staff or whether they'd like to see the province continue to directly fund their separate attendant care outreach program. It will be a decision made by the local consumers as to whether or not they receive their services from the MSA or from an independently funded organization. The eligibility criteria for the new basket of services delivered by MSAs would include the right for an MSA to deliver up to attendant care outreach levels of service for other clients who met those eligibility criteria.

Mrs Sullivan: The other issue is the one of transportation. You're the first group that's raised that as a problem. In the communities I've been in, I see transportation as a major problem, and the shift to the MSA is even more difficult. Transportation issues aren't easy. First of all, there's the disabled transport, which is in many communities handled by a municipality as part of its regional or municipal transportation system. In other communities it's a contracted service from the council. That's one type of transportation service. Then there's the volunteer transportation service to ensure that the person is taken to a treatment place or a respite care centre or a social activity. Then there's the more intensive transportation needs where a patient may be taken, by example, to and from chemotherapy services, where you want a higher level of skill associated with that transportation.

You talk about the rivalry between the Ministry of Transportation, Comsoc and Health over mandate. I'm not sure what those traditional rivalries have been, but it seems to me that if transportation in a generic sense is a required service under the bill, the government had better be very clear about the limits it wants to take transportation to, what it includes in transportation services the MSA has to provide. Otherwise we're going to see MSAs taking over every municipal disabled transportation service along with all sorts of other volunteer services that are now operated, and we will indeed approach the regional government size and reach that Mr Wilson spoke about earlier.

Mrs Barkey: I appreciate your understanding that transportation affects many programs. You think of adult day programs. In our rural area, just driving a distance certainly impacts on those who can participate because they have to pay both for the transportation.

In the current legislation, if a municipality wants to provide transportation, it can. As you can appreciate, with increasing costs not too many municipalities, if they don't have a program for the disabled, want to incur those costs. In our particular community there was not funding through, first of all, Community and Social Services or, latterly, long-term care for the provision of transportation, so we were able to manage, without any contribution from the municipality, to operate a van program, but we were only able to manage because we had service clubs get behind it, because we've had fund-raisers who got behind it and because we've had the ability to access a federal grant for conversion of the van -- those sorts of things. There just seems to be not a real sense of commitment to the urgency of transportation needs in rural areas.

I think you're right. Clarification is definitely going to be needed over whose mandate it is and whether others can kick in if that one stops, but certainly there must be a recognition of how important it is, and also in delivery of the services, the cost of delivering the service.

Mrs Sullivan: There's another issue associated with transportation that my colleague Steve Offer has raised in the House on a couple of occasions. It certainly affects my riding and the Mississauga ridings and I assume other areas of Ontario are affected; that is with respect to the licensing laws associated with the services being offered, frequently a taxi service or a transfer service, whereby the municipal licences that go to the edge of the boundary mean that a car or a vehicle which takes a person for treatment in Toronto can take them there but they have to be taken by a Toronto vehicle to the municipal boundary and then picked up at the municipal boundary by the Halton or Peel vehicle. That kind of nonsense has created havoc.

Mr O'Connor: That's the taxi licensing.

Mrs Sullivan: It's partly taxi licensing, but it's also the transfer services, I suppose, that are contingent.

Mrs Barkey: You're right. That's the kind of issue that's important to address.

Mr Wessenger: I'd like to clarify. First of all, if we look at the bill, when we talk about transportation services we mean providing transportation to persons who are unable to use existing transportation, so it's really where there's not an existing transportation system that the person's able to use and where there's the provision from the MSA. With respect to that problem of cross-boundaries, I believe it is solved in the legislation. Perhaps legal counsel could indicate the section.

Ms Czukar: It's the Public Vehicles Act exemption in 51. That says the Public Vehicles Act licensing requirement doesn't apply to vehicles that are being used by approved agencies to transport people who are eligible for those transportation services under that exemption. That's to apply to situations where agencies have a van or operated service of some kind and they've been challenged in the past by commercial providers. Often it's such a significant challenge that they park the van and don't provide the service, because the prospect of going through the hearings to obtain a licence and so on is too intimidating. So we've tried to deal with that issue, but I'm not sure it solves the problem of the taxi licensing.

Mrs Sullivan: Exactly.

Mr O'Connor: That's covered under the omnibus bill that's before the House right now. It's in there.

Mrs Sullivan: We'll support it, then.

The Vice-Chair: With that, the committee, at this late hour, will recess until approximately 7 pm. Members and staff are invited to supper in room 228.

The committee recessed from 1810 to 1906.


The Vice-Chair: Good evening and welcome to the standing committee on social development, presently holding hearings on Bill 173, An Act respecting Long-Term Care. The first presentation will be made by representatives of Senior People's Resources in North Toronto. Welcome to the committee. Please introduce yourselves and proceed with your presentation, and if there's time, there will be questions following the presentation.

Ms Bunny Segal: My name is Bunny Segal and I'm chairman of the board of directors of SPRINT. That's the acronym for Senior People's Resources in North Toronto. I'm here with several members of our board: Charlotte Maher, who in her professional life is a social worker; Barb Coupal, who is chairman of our long-term care committee of the board; and Freda Finley, the past president of the board. I'm also here with two of our staff members: Bau St-Cyr, our manager of home support, and Jane Moore, our executive director.

The comments we offer to you represent the perspective of the members of our board, our volunteers and our staff, and we feel confident that they also represent the perspectives of the people who donate to our agency and of the clients whom we serve.

We decided to meet with this committee for a number of reasons. First, we're here this evening to let you know that we agree with the underlying intent of the legislation and that we applaud this government's efforts to bring to fruition a direction that has been worked on in several iterations by several administrations.

We support the effort that is being made to help people remain out of institutional care as long as they are able and as long as they wish to, and to help them maintain a meaningful and comfortable quality of life for the time that they are in the community. Indeed, this is the reason that SPRINT was originally established: to provide seniors with the resources that will allow them to continue to be meaningful members of the community.

We also believe this legislation is attempting to enable people to get to the services they need with relative ease and with minimal delay. It recognizes that people in need of service often do not have the energy to seek out the services they do need from a variety of sources. It also seems to recognize -- at least we hope it recognizes -- that people have a combination of health and social service needs and that this should be mirrored in the practical integration of health and social services under a single umbrella of care.

Second, we are here because we believe we have an obligation to our volunteers, to our members, to our donors and to our supporters, as well as to our staff, to ensure that their investment in SPRINT is secure, that their efforts in creating and building this agency are indeed secure and that the quality of service people have received in the community and to which they have become accustomed will continue and will grow, and that a change in structure will not undermine in any way the community-based nature of the service and the sense of ownership the residents of North Toronto feel for the agency.

From the start, SPRINT has provided a wide range of support services to help elderly and disabled persons continue to live and be active members of the community. We have provided a comprehensive case management service, complemented by volunteer services of friendly visiting, transportation and escort and telephone security, as well as Meals on Wheels.

Our respite care program was the first in Ontario and based firmly on the belief that in order for people to be maintained at home, care givers need help too. In 1987 the Alzheimer respite care was expanded and care giver education and support groups developed. In 1988 we began homemaking, home help and diners' club services, and most recently, in 1990, we launched an adult day program.

Our excellent staff and more than 250 volunteers help approximately 2,000 people each year. These clients are often people living alone with multiple health problems and limited family and neighbourhood support. Almost 40% are over 85 years old and more than half have an annual income of a lot less than $15,000. They are served by our excellent staff corps and dedicated volunteers who gave close to 16,000 hours of service this year alone, and they represent a resource we want to see incorporated into any new system.

SPRINT has actually always provided one-stop access to service for our clients, and a wide range of services it is. But we recognize that things can always improve and, in that regard, we have formed a coalition with other organizations to broaden even further the services we provide. We see this as a positive step in the direction of a north Toronto MSA and, along with our participation on the north Toronto MSA steering committee, we look to contributing to bring long-term care reform to north Toronto.

The legislation before us today is a giant step in that direction. However, we want to share with you ways in which we believe it can be further improved so that it will actually meet its intent and ultimately serve the best interests of our community members.

Let me turn now to Barb Coupal, the chair of our board's long-term care committee. She can share with you our more specific recommendations.

Ms Barb Coupal: While it is clearly the government's and the minister's purpose to integrate community-based health and social services, we are concerned that the legislation does not in any way address or spell this out. We recommend that part I of the act, the purposes, be strengthened to ensure the reform in fact does integrate health and social services. As a neighbourhood community social service agency, we are most concerned that after the reform the system does not continue to be driven by the health care sector as that simply maintains the status quo.

The legislation appears to give the minister unilateral power, for example, in altering geographic areas for MSAs. It is clear from the process to date that the government and the minister intend to use community consultation and due process. We recommend the legislation clearly reflect the government's intent and clearly state that the norm does require due process and community consultation prior to the minister's decisions.

The legislation refers to approved agencies. It appears that there will be interim, as well as ongoing, approved agencies. We suggest it is confusing to provide for both interim and ongoing approved agencies in one piece of legislation. We recommend that the reference to interim approved agencies be removed from the legislation and dealt with in a separate document or in the regulations. This is also important because enshrining interim approved agencies in the legislation could inadvertently serve as a block to the real integration of health and social services.

Again, we are fully confident that it is the government's and the minister's full intent to provide for a consumer-focused service. We, however, have concern that the legislation does not in fact encourage client-centred service. We note that in section 20 the agency decides the service plan while the client has only an opportunity to participate.

By contrast, at SPRINT our philosophy is that the citizens have a right to participate in the shaping of the service plan. In our assessment we work with the client and the family to determine, in the first place, what is wanted rather than what is needed. Our belief is that needs are defined by others while wants are defined by the consumer. To be truly client-focused requires a focus on client wants and, having determined what is wanted, then participating with the client to determine what service plan can realistically be put together. The client remains in the driver's seat throughout the process.

Also, in regard to consumer focus, we are concerned with the bill of rights, that it puts too great an onus on the client to make a complaint while it does not sufficiently specify the obligations of the agency. Further, we are concerned that the legislation makes no reference to the right of access by citizens. From a client perspective, there is nothing in the legislation to indicate that indeed a community service will be available when required.

We recommend a revision to the bill of rights and to section 20 to strengthen the client-centred focus of the legislation and to ensure the right of access to the service.

We just very briefly want to raise a question around the expected decrease in fee revenues. Our question is, with a significant decrease in fee revenue, how will the government plan to make up the shortfall without the risk of service reduction?

We are concerned that the list of community support services in part II, section 4, omits two services critical to helping citizens remain in the community. These two services are currently provided by SPRINT and currently funded by the long-term care division as community support services. We do not understand why they have been omitted. We refer to our respite care service and our client intervention and assistance program. Our staff will elaborate on the value of these services.

Mr Bau St-Cyr: As the agency that pioneered in-home respite care for the elderly in 1986, we're very concerned that the role of respite care is unclear in the legislation. Although respite is included in the definition of "care giver support services" in subsection 2(1), it is not defined or listed as a separate community support service in subsection 2(4). We feel that in-home respite care, as currently funded by the long-term care division, needs to be listed as a distinct program area alongside other important services, such as Meals on Wheels, transportation services and adult day programs.

In-home respite care is a program, as you probably know, which has a very wide scope and can provide quick and flexible assistance to care giving families. It is a service which complements other care giver support services, such as adult day programs, support groups, counselling and assistance and other supports listed in the legislation. It is also a program which offers benefits and services to families that are not available in any of the other care giving support programs.

These benefits include the flexibility of one-to-one care plans; extended relief through night, weekend and overnight respite service; the provision of care regardless of medical condition; the fact that the service recipient does not have to leave the home environment in order to receive service; and the fact that there's no need to engage in group activities if the service recipient is either unable or unwilling. Essentially we're sending someone into their home, in their environment.

The program, and this is a crucial point, is also available to care giving families who simply need relief from the care giving burden and companionship for the service recipient without having the need for either personal support or homemaking. It is a program that simply exists for providing care giver relief and support so that the person providing care can in fact continue to do so.

It is of course unreasonable to expect one care giver to provide three consecutive eight-hour shifts of care giving on an ongoing basis, day after day after day, without resorting eventually, after burnout, to institutionalization. If we are in fact going to try to keep people in the community, we feel at SPRINT that we definitely need to look at respite care and define it in a much clearer way in the legislation.

We have a case study we want to share with you very quickly. Mr and Mrs G presently use SPRINT's in-home respite care service. They live together in an apartment in north Toronto and have two children, both of whom live outside the city. This leaves Mrs G as the sole care giver to her husband, who has short- and long-term memory loss. Mr G also has physical problems. He has angina and problems with mobility. He's exceedingly anxious in groups, which makes him unsuitable for our adult day program. He's very suspicious and prone to wandering and cannot be left alone. Coupled with all of this, Mrs G's health has begun to deteriorate. Prior to accessing the respite care service, Mr G, an intelligent man, spent most of his waking hours in front of the television set being entertained by television or in fact staring at the doorway. Mrs G felt, and was in fact, completely imprisoned by the situation.

The provision of 15 hours of respite care service weekly to this couple has accomplished a number of objectives: relief for Mrs G; flexible respite scheduled to meet her needs; minimal anxiety for her due to the one-to-one contact in a familiar surrounding, thus minimizing the risk of angina attack; help with personal care and housekeeping; importantly as well, care for the service recipient: cognitive stimulation for Mr G, outings to the ROM, to the zoo, to Harbourfront, walks in the park, lunch in restaurants and the companionship of a brand-new male friend coming into his home and having a very important relationship with him; also, of course, the delay or possibly the avoidance of institutionalization.

It is our feeling that if this reform truly seeks to provide supports to enable families like the Gs to maintain themselves in the community, we must ensure the creation of a continuum of services able to assist care givers in all situations. In-home respite care is a key part of this continuum and needs to be recognized and funded as such.


Ms Jane Moore: The other service that is not listed in the legislation, as mentioned by Barb, is client intervention and assistance.

With this funding, because currently it is a funded program, SPRINT provides intensive case management to citizens with complex needs and who are at high risk of institutionalization because of a combination of factors, such as physical frailty, mental confusion and minimal supports from family and friends.

We estimate that this intensive case management service is needed perhaps by only 5% of the seniors' population. But for that number, the client intervention and assistance service is often the critical factor between remaining in the community or being institutionalized.

Client intervention case management staff assess strengths and deficits with the client in the areas of mental health, physical health, their activities of daily living, social networks and economic resources. On that basis the staff and the client agree upon a plan of action which tends to be very complex, being complex cases, and involve a very wide range of players.

Our client intervention and assistance case management workers are highly skilled in community-based geriatric work. They have assessment skills; they are familiar with community resources; they have the advocacy skills to deal with bureaucracy, cut red tape and bring about needed services; they understand psychosocial needs; they have the counselling skills needed to work with complex family dynamics; and they understand the importance of and are skilled at strengthening social networks.

The SPRINT client intervention and assistance case management staff act as travel companions, as we say, "walking with" the client as needed and serving the client over the long haul.

Crisis intervention obviously is part of this service.

The program provides the least intrusive service possible, views clients and their families holistically, aims to uncover and build on inherent strengths which we believe are present in even the most complex and difficult cases.

Just a quick case example: Miss K, a 95-year-old single woman, has lived with a friend for 40 years. The friend was hospitalized with a broken hip. Miss K was referred to SPRINT by the super in her apartment building. A good neighbour had been involved, but became quite helpless with the situation and wanted to withdraw. The immediate concerns were meals and twice-daily eye drops. Over the next two weeks, it developed that the friend was not going to be coming home.

The SPRINT intervention worker visited with Miss K to determine what was wanted, took her to visit her friend in the hospital and discussed with the two of them what steps might be taken. Our worker initiated joint planning with the hospital staff for both the women, did advocacy work to ensure ongoing nursing visits re the eye drops, coordinated evening homemaking services and did counselling to help the neighbours continue to be supportive.

SPRINT volunteers were recruited to do daily security checks. Another was recruited to do friendly visiting, crucial to helping Miss K remain rooted in reality and prevent her world from shrinking even further. With the intense involvement of our worker, the situation stabilized. Miss K is able to function in her apartment, knowing that her SPRINT worker is available at the other end of the telephone as needed, as well as being supported by the volunteer driver who takes her to the hospital to visit her friend, the security check and friendly visitor, as I mentioned. As well, her neighbours, with our worker's help, now feel that they can pick up again and continue to support Miss K. We hope and in fact expect Miss K will soon feel up to trying our diners' club or our peer support group to develop some new friendships.

We do not doubt that but for our client intervention and assistance program, Miss K would have remained extremely distressed, upset, unable to cope, her neighbours would have withdrawn support and she would have quickly been institutionalized.

We also point out that the client intervention and assistance case management service as provided by SPRINT is also provided by other home support agencies across Metro and that it is entirely unique. Neither hospital discharge workers nor hospital social workers nor home care coordinators have the mandate to provide the intense, ongoing case management as described. The loss of this program will ensure an even greater number of people requiring institutionalization. Thus, we strongly recommend that the current client intervention and assistance case management service be included in the legislation as a community support service.

Ms Segal: To just summarize, what we want to avoid is a bureaucracy where people are vulnerable by their dependence on a single source of help. What we want to avoid is a bureaucracy that has no allegiance to the community and that achieves efficiency at the expense of flexibility. What we want to avoid is a system totally funded by and accountable to the government, not the people it aims to serve. What we want to avoid is a pseudo-integrated system, essentially operated and controlled by the health sector, in which health care needs are paramount and quality of life is defined by the ability of the body to function.

What we want to ensure is an integrated system where people are treated as a whole, where health and social services draw no lines and where the client, as the consumer and actually the person who does pay for this whole service system, calls the shots on his or her own behalf.

Mr Jim Wilson: Thank you very much for your presentation and the annual report. Some of the statistics contained in it are quite impressive in the numbers of people you serve. Indeed, in the supplement to your oral presentation, there's a bit of a description of a couple of the programs you mentioned, such as client intervention and assistance case management and the in-home respite care program, and I note also that you had an emergency quick-response respite care program, which by the sound of it was quite successful.

I wanted to ask you really just one thing, and that is with respect to the multiservice agencies. I assume discussions are ongoing in your area now, if you could give us a feel for how things are going and where you think they're directed in your specific area with respect to who will end up being the MSA and what it will look like. We're quite in the dark with respect to what MSAs are going to look like and how they're actually going to function. Some people are coming to this committee for answers. I can tell you that the committee is looking to a number of the groups for answers because the legislation isn't terribly specific in areas of giving us a good overview of what the MSAs will actually look like, who will be on them and how they will operate, so perhaps you want to tell us that.

Secondly, I have a question, which was the group's question about the decrease in fees. Perhaps the parliamentary assistant will want to address that. I don't see how there'll be decreases in fees, and maybe you can explain that to me, since you made the comment and asked the question.

Ms Moore: In the North Toronto community, we have an organization called People and Organizations in North Toronto. It has spearheaded the community consultation process that we believe will lead eventually to a North Toronto multiservice agency. Many North Toronto players are participating in this development, including a wide range of consumers, a local hospital etc.

Mr Jim Wilson: And how's it going?

Ms Moore: There are difficulties on the road towards the local MSA, without a doubt. There's the health sector and there's the social service sector and it's going to be difficult to have the true integration and not have the domination. From our perspective, we are considerably worried about the domination by the health care sector.

Mr Jim Wilson: I had a second question, which was the decrease in fees. Could someone just please explain that?

Ms Coupal: As things stand presently, approximately 25% of our budget comes in the form of user fees, so our concern is that, as we understand it, we're going to have an envelope of money with which to serve our clientele in a new MSA, and we have concerns about that lack of contribution by the individual and how the shortfall will be made up.


Mr Jim Wilson: The whole long-term care reform actually includes a huge increase in user fees, and they are permissible under this act. Maybe the parliamentary assistant would like to clarify.

Mr Wessenger: I don't know whether I can clarify because we'd have to know what you presently charge fees for and to see if there's any aspect of the prohibitions. In order to answer the question, we'd have to have a list of the fees charged and that would have to be reviewed by the ministry. But perhaps I can have a policy person indicate generally what the situation is with respect to fees.

Mr Quirt: The bill allows for fees to continue for a number of community support services that normally have had fees associated with them; for example, fees for meals delivered to people's homes, fees for volunteer rides to the doctor or shopping, fees for home help when a student might come and rake the leaves or clean the basement of an elderly person's home.

There are two changes with respect to fees in the community service sector brought about by the long-term care reform. One of them relates to the way in which user fees would be arrived at. We have a program design work group advising us now on how best to establish some more consistency in user fees for those programs I've mentioned. I suspect what will happen is that they'll recommend to us some principles about user fees. For example, they may recommend that when it comes to meal programs, the client should pay the cost of the actual food or whatever, or establish those types of guidelines that agencies can use across the province. I doubt very much whether they'll recommend to us that one flat, standard fee be applied in all circumstances everywhere.

The second change with respect to user fees relates to day programs. Consistent with our approach in long-term care facilities, we don't want our consumers paying for their care or services or programs, so we will be offering day care programs without a user fee. User fees for day care programs now vary from program to program. Some are free now, some aren't, and the percentage of revenue generated from day programs is a relatively small percentage when compared to the revenue generated from meal programs and transportation. Clearly, MSAs and home support agencies will have their budgets adjusted to reflect that. Currently, some of our programs are losing revenue from the home care purchase of meals, and in those situations we are adjusting the budgets of agencies to make sure that shortfall in revenue is made up by provincial subsidy.

Mr Jim Wilson: Perhaps I can just add that if we look at 1993-94, the statement of revenue and expenses from SPRINT, there's a considerable amount of money brought in under the adult day program. The expense recovery line item is $293,628. Is that perhaps what you're referring to?

Ms Moore: No. If I could clarify that, we have a contract arrangement with a local community health centre. That's a transfer, so that does not reflect entirely fees. We do receive significant fees for services that would qualify as personal support services. People currently receiving SPRINT homemaking services and paying for those services, as we understand it, under the new legislation would no longer be paying for those services. So we do expect a very significant decrease in our fee income.

Mr O'Connor: I appreciate you coming forward. We've heard a number of concerns being raised, and no doubt we will as we hear from people who are out there providing what they feel and what are in fact good services today.

A caution that is quite often placed before us as legislators is that when you try to define as much as you possibly can in legislation, you end up excluding stuff. I think there's usually a caution put in place so that when there are a number of areas you'd like to see put into the legislation, there's a reason for not everything being spelled out as clearly as you possibly could in the legislation, because that creates exclusions, and that's not the intention. The intention is to provide for the needs, for the services that the consumers require out there, and some of those services will evolve. You talk about the respite care program that you offer, and 10 years ago -- how long ago was it?

Ms Moore: It was 1986.

Mr O'Connor: Less than 10 years ago; it didn't exist. So if we were 10 years ago doing this, something like that could have been excluded, and who knows what else. I hate to see things defined too narrowly, because then you create exclusions.

One of the things we have heard over and over again and will probably be a recurring theme is that the development of the MSAs is going to cause the loss of volunteers, that they're not going to be able to provide the same basket of services that is being provided today because you could be excluding groups out there that are providing services. We've heard from groups like the Saint Elizabeth Visiting Nurses that, "You're going to exclude us and that service isn't going to be provided, and it's a needed service."

What you could offer us is maybe some advice on how we can make sure the MSAs, as they evolve and develop, are not a bureaucratic nightmare, the bogeyman, something terrible, because I think what you've demonstrated in the short period of time that you've been around is that you can bring in a lot of community services under one roof and provide a very comprehensive set of services. The key here is going to be focusing on what the needs of the consumer are and making sure those needs are met. So if you could offer us some advice as to how we might be able to share that, I'd appreciate that.

Ms Freda Finley: One of our major concerns is the retention of not only volunteers but volunteer dollars. We feel that we have a very strong commitment from our volunteers at this point because they have an input into the programs we provide: They sit on our committees; we have a very active board. Our concern is that if the MSAs are set up in a way that does not maintain that accountability to the community, there is a serious risk of losing both the volunteers and the dollars.

Having said that, we have very committed volunteers whose major commitment is to the client, and they will continue, but the dollars and the commitment from the community to be involved in the policy, in the delivery of those services, I think is seriously at risk if it is perceived to be a bureaucracy.

Mr O'Connor: The local planning I think is going to be essential here for the retention of the volunteers and for the network. Local planning is going to be a key to the development.

Ms Finley: I guess my concern is that I don't see that addressed in the legislation.

Mr O'Connor: Do you have any suggestions?

Ms Finley: I'd be happy to give them to you, but I don't think you've got enough time tonight. The issue of governance isn't really addressed in the legislation. It was discussed at great length in the deliberations beforehand, and it was a great disappointment to us to not see it there.

Mr O'Connor: Because they need to evolve locally, and if we were to put down something -- like I said, once you start establishing everything in legislation, then you're excluding too much, and for it to evolve locally, it does need that development to take place.


Mr Jim Wilson: But you're going to do it through regulation and there's no public input in regulations.

Ms Finley: That's right. I mean, if it's going into regulations --

Mr O'Connor: It's not going to be. It's not going to be completely that way.

Ms Charlotte Maher: Yes, but you've got to have some guidelines to that. One of my major concerns in this legislation is that the interim period and the long-term period are not divided up. They seem to be merged in the legislation. That was mentioned by Barbara. But what that does is confuse the issue. The interim period must aim towards the end period, in my view. The interim period can be four years or five years or two years or however many years, and during that period it seems to me there need to be some guidelines to the communities in order to have -- but we've got books and books and books. Many, many volumes have come out on this thing. It's not foggy -- at least, some of the details are foggy, but the thrust is not foggy, I do not believe, and I believe the thrust as it has been described by the minister is quite consistent with the thrust that was very neatly expressed, I thought, here today in terms of where the power is and who's in charge.

Mrs Sullivan: Dianne Poole, who's a member of our caucus, has described your agency frequently in our caucus discussions of long-term care reform and is very much your advocate, I will tell you, around this place. I'm interested in some of the comments you've made with respect to funding issues. You're the first organization that's brought in its balance sheet so that we can actually address the actualities of revenues and so on. I note from yours that your non-government funding amounts to about $231 million vis-à-vis --

Ms Moore: No, thousand.

Mrs Sullivan: Sorry, thousand. Wouldn't it be great if it were million? It's $231,000 --

Mr Jim Wilson: That's including Barbara's personal contribution.

Mrs Sullivan: -- versus Comsoc funding of $781,000. That's a very high proportion of your total revenues. Questions other than the volunteer donations and the fund-raising which are recorded in your statements relate to whether in fact the MSAs would continue to be eligible, by example, or qualify for the kinds of municipal funding that you're receiving. Ontario Trillium Foundation funding and I think United Way have already expressed considerable reservations about funding MSAs. Certainly, they have in my community and I understand the same is the case in Toronto.

I think the funding issues won't go away and they're going to have to be resolved. Either the government has to agree that the service levels that are going to be required will be funded by the province or we have to understand that the promises that are being made to people with respect to the way this act will unfold as it's implemented are in fact not going to be kept.

I've got a couple of questions to ministry officials, first with respect to in-home respite care, wondering if those services are included under community support services, item 3, care giver support services, for which charges can be made or fees are allowed.

The second is the client intervention and assistance, the case management that you spoke about. Is that included under the social work services as professional services for which no fees are allowed? We've got to know what the government means by the words that are there. They may be included or they may not be included, but we should understand what's there.

Mr Wessenger: I will ask legal counsel to respond to that.

Ms Czukar: With respect to your first question on respite care being part of care giver support, the answer is yes, it's included in the definition of "care giver support services," it's a community support service. Subsection 25(2) says that if an approved agency provides a community support service in accordance with the plan of service, it can't charge for it except in accordance with the regulations. So if regulations are made that would allow an agency to charge fees within a range of fees for that kind of service, then they could charge; otherwise they couldn't.

I'm not sure I caught all of your second question, if you could just repeat that one.

Mrs Sullivan: The client intervention and assistance, which is the case management approach that's been adopted by SPRINT --

Ms Czukar: Right, okay.

Mrs Sullivan: -- largely, I think, under the leadership of social workers who coordinate the teams and whether that service would be included as a professional service under subsection 7(2), social work services.

Ms Czukar: Case management is really defined in section 20, which is the development of the plan of service assessing requirements with the participation of the family and the person, determining what services the person's eligible for, what the plan of service should look like, and then section 21 is saying that the services should be provided. That is really the description of the kind of case management service.

The reason case management service isn't articulated as a specific service in the four categories is because we had to come up with a description of what was included, because there are so many descriptions of what a case management service is. This was the way that we ended up with it: as an obligation on every approved agency to assess requirements with the person's participation and so on.

So that's where it is and it could be done by teams or by a case management worker. I guess MSAs could work out different staffing structures for how they wanted to best accomplish it.

Mrs Sullivan: My last question relates to the kinds of integration that you've attempted with the community services that your organization offers and health services which are offered by other agencies. I noticed that at one point you did a pilot with the VON. Can you tell us where that ended, or has it ended?

Ms Moore: No.

Mrs Sullivan: All right, so it's still ongoing. Then, in the next case, would you contemplate applying or pressuring to become an MSA?

Ms Moore: Sorry, what was the last part?

Mrs Sullivan: Would you contemplate applying or pressuring or whatever the process is to actually be named as the MSA for north Toronto?

Ms Moore: We had understood that no agency was to be an MSA, so we have gone on that assumption. Could we have comment --

Mrs Sullivan: Could the ministry confirm that that's the case? This is highly problematic, particularly -- I say particularly in communities outside of Toronto, but that may not be the case; that might just be my prejudice because I'm from outside of Toronto. But let's have a clear statement of whether an agency can be an MSA or not.

Mr Wessenger: Certainly it's my impression it can, but I will ask policy to --

Mr Quirt: Very clearly, we do expect that many of our existing agencies will become multiservice agencies. There's absolutely no provincial direction to suggest that some of our existing home support or other health provider agencies can't become an MSA. That would be quite a foolish statement for us to make.

As a matter of fact, what we're hoping is that consensus will be reached through the DHC long-term care planning process about which agency is best equipped to become the MSA, whether it's two agencies or three that join together, whether it's one existing agency that expands its mandate. In some places, it may well be that the community planning process says, "Well, heck, let's start a new agency, because that's what the consensus is around the table here." I suspect that it would be in the minority of cases that an existing agency or group of agencies wouldn't form the nucleus of the MSA.

So clearly we're not saying it has to be a new agency. In the discussions around the Metro Toronto situation, with over 100 agencies in Metro Toronto and a DHC recommendation for between 15 and 20 MSAs, there may well be some other perspectives from the point of view of the long-term care planners in Metro about which I'm not aware. But there's certainly no provincial direction that an existing agency can't be an MSA.

Mrs Sullivan: If the province, though, concurs that an existing agency, as a policy matter, can/should become an MSA, what control over the DHCs is the province going to take? Is the province going to say, "If you rule out an existing agency, DHC, we're not going to accept that, if there's an appropriate agency," and, "Please look for an appropriate agency"? Is the province going to just leave it all out to this vast unelected body to do these things?

Mr Quirt: No; the province is looking for advice from district health councils and from long-term care subcommittees. The province has specified the composition of those long-term care subcommittees so that perspectives of consumers, perspectives of social service providers and perspectives of health care providers are reflected in those discussions.

We have confidence that the district health council process, given its representativeness and given its direction to ensure that social and health perspectives are fully considered, will give us good recommendations on what their community feels is appropriate.


Obviously, it is advice that the minister gets, and in the off chance that it's bad advice she gets, she may well choose to decide alternatively, but we're certainly not starting out on the premise that the community planning process is going to provide bad advice. We expect that nine times out of 10 it's going to be solid advice based on a consensus arrived at at the community level. That's a much better alternative than simply directing from Queen's Park which agencies or organizations should become MSAs.

The Vice-Chair: Ms Sullivan, had you completed your remarks?

Mrs Sullivan: I think that the presenters have a response.

The Vice-Chair: Yes, please, go ahead.

Ms Maher: This is absolutely counter to everything I've heard so far. One, and I quote -- I'm not going to quote, but I'll give you the gist of where I got this idea. The so-called salmon document clearly is quite different in terms of that. I'm talking about Metro, but I remember hearing the minister at the initial Metro conference, where we began the business of long-term planning, when she was absolutely clear when asked if this were to be the case. I've subsequently heard -- what was her name? -- Karen Goldenberg indicate there will be a transition period during which time one of the agencies may assume these responsibilities, but this is not the intent in the long run. I'm astounded to hear you speak that way.

I don't think that it's just Metro. I think this is more broad than that. This is the kind of thing I think is dangerous and serious in terms of the community planning process. You can't just shift gears midstream. No one's going to believe you or care. It's a very serious matter. I believe the community planning process can work but it can only work with some consistency in direction, if the guidelines are consistent. I'm astounded.

Mr Quirt: The point I was trying to make is that the province has not directed the community planning process and DHCs, that under no circumstances can you recommend an existing agency become a multiservice agency. We have not done that.

In the discussions in Metro Toronto, given the complexity, it may well be -- I don't know, but it may well be -- that the MSA subcommittee and the deliberations of the DHC in Metro are leaning towards the establishment of new agencies. It's not a provincial policy that they be new agencies. It is a provincial policy that the local DHC-led planning process make recommendations to the minister on which agencies become MSAs or how MSAs are formed. To that end, in Metro Toronto, I understand that there are, in about 15 communities, a number of agencies that have formed planning consortia that are sorting out among themselves how best to establish a multiservice agency in each of those geographic areas. We're prepared to support that process by providing facilitators or providing a grant to each of them of between $5,000 and $25,000 to let them develop their MSA proposal.

It is not our position at this time that we preclude an existing agency from being recommended as a multiservice agency. Once that's recommended, then obviously that agency would have to meet the expectations of the province in terms of board composition and other expectations, and it's conceivable an existing agency would have to reconfigure its board to make sure that consumers were adequately represented, for example. But there's not a provincial direction to preclude an existing agency from becoming an MSA.

Ms Moore: I guess I would suggest that this information be made public, particularly in Metro where organizations like SPRINT are really turning themselves inside out trying to figure out how we in effect dissolve, which is what we understand we have to do, and resurrect in this new MSA form.

As it happens, in north Toronto SPRINT is really it in terms of home support, so it's not as if there's this plethora of agencies that have to be amalgamated. There's SPRINT and there are two very tiny, one-service agencies, SAINTS and Yorkminster. The three of us have an integrated client database; we work together very well. What we need at this point is to integrate with the Metro home care program. If we accomplish that, we will have accomplished a north Toronto MSA, but because our understanding is that the whole world has to be involved in doing this, we've gone back to square one and we have this really quite major community planning process in the works which includes, for example, the local hospital who is very interested in determining how this MSA is going to develop, and has become a very complex process.

Ms Segal: And if I could add to that, in the process of doing that we will spend the $25,000 that you so generously want to give us to do exactly what you say we don't have to do.

Ms Finley: Precisely.

Ms Maher: Something's very wrong.

Mr Quirt: Just to further clarify, the process to arrive at which agency, new or existing, should become the MSA has to be a collective process; it has to involve the various stakeholders and people like hospital representatives and representatives from home support agencies and representatives from health-care providing agencies and a consensus has to be reached.

It may take a while and it may take some money to help that consensus be arrived at, but that consensus, from the provincial policy perspective, does not have to be -- we have not sent out an edict that every one of our transfer payment agencies is hereby dissolved and everywhere in Ontario there has to be a brand-new entity called the multiservice agency. We have not said that and we expect that existing boards will happen.

Mrs Sullivan: That's been said on many, many occasions.

Mr Malkowski: The issue that you had raised earlier just in regard to client intervention and case management as well as in-home respite care: Having heard your concerns regarding it not actually being in the legislation itself in terms of a mandatory service for all MSAs, if I could give you two options.

Right now there is the flexibility for MSAs to include a variety of services which would include those types of services. Do you feel satisfied with that, or do you think that it actually has to be spelled out in black and white in the act?

Ms Moore: While we did hear Larry O'Connor's suggestion that the more you spell out the more difficult it can become, nevertheless, because all the other funded services that SPRINT currently provides are spelled out but there is the omission of client intervention and respite care, we feel this is very significant and we think it is critical, given what we have described to you as to how important those services are to help people remain in the community, that they be reinstated.

Mr Wessenger: I think I'd like to have the policy adviser give some clarification on that.

Mr Quirt: I'd just like to assure the delegation that the intention of spelling out the mandatory services in the bill was not an intention to preclude or to eliminate some of the important, innovative, flexible, needed services that we now fund. The intention was to make sure that when MSAs were established they were inclusive in terms of the services provided.

Let me assure you that the type of in-home respite service that you're providing is precisely the kind of thing we'd like to see across the province, the kind of innovative support to care givers that's needed. In addition, the client intervention service that you're providing -- you could describe it as client intervention; you could describe it as intensive case management -- we applaud you for that and we hope that more organizations will do it. It's precisely the kind of thing that we think is going to improve the community service system and is going to allow more people to live at home rather than accessing care in a facility.

Respite care is a difficult thing to define in a bill in that, as you know, respite care can be provided by a volunteer who visits, respite care can be provided by a homemaker who goes in and does some homemaking activities while a care giver takes a break, respite care can be provided by another professional like you employ, or it could be provided with a short stay in a long-term care facility. So respite is a bona fide, legitimate and important objective of a number of different aspects of the service system that we want to create.

The Vice-Chair: Any final comments that you'd like to make?

Mr St-Cyr: I have a comment related to respite care. Respite care has been provided for ever, because for ever we've had family members that have become ill, that have become frail and that have needed support by their family members and the community. Recently, it has been provided through programs called homemaking programs.

Respite care, to be significant, has to be provided in a large enough number of hours to allow a care giver, who is providing constant 24-hour care, to get out and really get a break. Homemaking programs, I would submit, have not been funded to provide that level of care. The type of respite care we're getting currently under the integrated homemaking program requires the need for personal care. Not all care givers need personal care. They need respite care. The type of respite care available through homemaking programs funded under home support agencies cannot begin to address the need of the families, because the funding is so limited and homemaking programs generally are offering three to six hours of homemaking a week to a family. Respite care to have an effect for some families is needed in excess of 15 hours, in excess of 20 hours. So to hide respite care in homemaking or under personal support means making it disappear in areas where it exists currently. I would really suggest caution in this area.


Mr Quirt: It's certainly not our intention to hide it there. For the very reason you've pointed out, we do now fund you to deliver the kind of home support in home respite service you describe. If we thought it was a lousy idea, why would we be funding you now?

Mr St-Cyr: Yes, of course. I wasn't suggesting that you were maliciously hiding it. I was just suggesting that we would like to see it come out a little bit more in the open because we see it as such an important part of community supports.

Mr Quirt: We agree. It's a very important part. We thought we had addressed it specifically. We described respite as a bona fide reason for delivering service even if somebody can't be defined as in need of professional health care service or in need of personal support, or whatever, the family being the client as opposed to the individual. We take your point that if you've misconstrued it, other people may as well.

The Vice-Chair: Thank you for your presentation. Pleased to hear you this evening.

Mr Jim Wilson: While we're changing groups, could I just ask for a bit of information from the parliamentary assistant. One of the points that this group raises, and particularly with the question of fees is -- the way this bill is written is if you get a plan of service, if you're eligible for a plan of service, you get your services free. If, for example, respite care is included in your plan of service, there's not to be a charge for it, even though it falls, apparently, under community support services where there may be charges for some of those services if it's not part of someone's plan of care. I guess what we need to know is, how do you become eligible for a plan of care? If we look at section 20, we talk about the assessment of a person's requirement -- sorry, plan of service. What the heck is the name of that?

Ms Czukar: Plan of service.

Mr Jim Wilson: Plan of service. I mean, basically if you don't get on the plan of service, you're in trouble in this system. I think where the narrowing of the system comes in is who becomes eligible. As far as I know, I haven't got any notes on eligibility and assessment, and it is rather crucial because you can't access this thing in a cost-efficient way if you don't win the jackpot.

Mr Wessenger: I'll ask counsel to respond to this. I think the section you're referring to is section 25, where you're quite right, that if --

Mr Jim Wilson: Well, 20 through to 25.

Mr Wessenger: "If an approved agency provides or arranges the provision to a person of a homemaking or community support service...the approved agency shall not require payment...except in accordance with the regulations."

Mr Jim Wilson: But it would be important for a group like this, for example, with the myriad of clients it has, in order for budgeting purposes, for example, they would need to know how many existing clients that are receiving services at cost or no cost, how many would actually be assessed to qualify for a plan of service and therefore have no cost.

Mr Wessenger: I will ask legal --

Mr Jim Wilson: It would be very, very difficult, at this point, to --

Ms Czukar: That's right, and the eligibility criteria will be in the regulations. So the eligibility criteria, just as they are for facility services, will be the guidelines that the approved agencies use to determine what kinds of services people are eligible for and what the limits of those services are. That's what is to be in the plan of service as described in section 20.

Mr Jim Wilson: But I would have thought, though, after we went through this in Bill 101 and eligibility criteria to get yourself or a loved one into institutional care, that the government of the day would have learned something about the displeasure we expressed last time about this. Do you want us to go through that again now for the next five weeks, about having no eligibility criteria here and yet you want us to endorse legislation? We don't even know who's going to be able to access these services.

Mrs Sullivan: Or what level of services or at what --

Mr Wessenger: We can ask policy. Maybe he can provide more clarification on the --


The Vice-Chair: Please.

Mr Jim Wilson: I thought we made it clear a year ago or two years ago we did not want --

The Vice-Chair: Please. We will not have cross-conversations, and we'll have one speaker at a time from now on. Would you care to respond, Parliamentary Assistant?

Mr Wessenger: I think Mr Quirt would like to respond to the eligibility question.

Mr Quirt: We'd be happy to provide to the committee a presentation on the eligibility criteria. As members of the committee would know, the eligibility criteria for any community service are nowhere to be found in any legislation currently. We have eligibility criteria in place now, and representatives before the committee are familiar with some people not being eligible for home care services or, in fact, some people not being eligible for some of the services that SPRINT provides with funding for home support services.

Those services that are necessary in order to maintain someone's lifestyle independent in the community, those services necessary to allow people to remain at home as opposed to moving to a facility, are those services that will be included in the plan of service and not charged for.

If you, Mr Wilson, were to ask SPRINT for a homemaker, they would determine a reasonable fee and charge you that. In that case, they'd determine that you didn't need that service to maintain your independence in the community. All of our community service agencies across the province are familiar with some clients who aren't deemed to be in need of the service being charged a fee, and others not, in that the Red Cross and the VON and many providers are in the business of both providing publicly funded and supported services for clients of the system and also offering services to other people who don't meet the eligibility criteria of government-supported programs.

Mr Jim Wilson: I understand that and I appreciate that. So what you're telling me is that the eligibility criteria --

Mr Malkowski: On a point of order, Mr Chair: I know that we have a very long list of speakers and we are over an hour on just the first presenter. I wonder if we can move on.

The Vice-Chair: Yes, that's correct. We are slightly over an hour, in which case --

Mr Jim Wilson: I'd like to take Mr Quirt up on the offer, if we could set aside 15 minutes to go over eligibility criteria that currently exist and what it's going to look like in the passage of this bill.

The Vice-Chair: Thank you. That's very --

Mr Quirt: I'd like to suggest to the committee that we have an outstanding presentation on the technical aspects of the bill which we could incorporate in perhaps a half-hour presentation, and we'll be able to cover off the determination of eligibility at that time for you as well. We're getting a lot of advice currently from our program design groups on that topic.

Mr Jim Wilson: Let's do that.

The Vice-Chair: Thank you. That would be very helpful. That will be later tonight perhaps, or some other date.

Interjection: Not later tonight, no.

The Vice-Chair: Well, I've got a one-day stint at this, you see.

Mr Jim Wilson: I hope you won't mind sitting through the presentation and telling us what it was like.

The Vice-Chair: Thank you for your presentation. You can see there's very keen interest in your presentation and your remarks.

Ms Segal: Thank you for your time.



The Vice-Chair: The next presentation will be made by representatives of the Community Hospice Association. Welcome to the committee. Please introduce yourself when you're ready and proceed with your presentation. Hopefully there will be time for questions following your presentation.

Ms Heather Balfour: First of all, I'm very pleased to be able to be here this evening to present to the committee. We certainly appreciate this opportunity. Marilyn Davidson, the chair of our public policy committee, is unable to be with us tonight, so it will be myself who is doing the presentation.

I am Heather Balfour and I'm the executive director of the Community Hospice Association of Ontario. I have brought with me tonight a written presentation which I'm not going to belabour. I know we're not having a lot of time this evening to talk about a lot of things, so what I would like to do, briefly, is three things tonight.

I would like to talk to the committee briefly about hospice and what hospice is in Ontario, because we do find that we're not a very well known commodity. Then I would like to talk about some of the concerns that we have in the hospice field with the act, and with some of the happenings we see in redirections in long-term care and in the development of MSAs in terms of hospice care. I'd like to end on a more positive note in terms of some recommendations that we have as to how the process can be easier for everyone who's involved.

First of all, I'd like to talk about hospice. I am an employee of the Community Hospice Association of Ontario. We're a fairly new organization, we've only been around for five years. We were established in 1989. At that time we had eight hospice programs in the province. We've now expanded to over 60 hospice programs. I think that's a telling factor in what's happening with people with terminal illness in the province. We are seeing a dramatic increase year by year in the number of hospice organizations being developed, as well as the number of clients and families that are being cared for by each hospice program and the number of volunteers who are becoming involved in caring for people in the hospice field.

In terms of what it is actually that a hospice does, hospice cares for people with a terminal illness and their families. The intent of most of our hospice programs is to care for people in their own homes, although of the 60 programs we have now, we do have one that has a freestanding building which, of course, is Casey House in downtown Toronto.

The philosophy of hospice includes the fact that the client is a director of the type of care that they're getting and the service providers who are coming to them in their own homes. So in very many ways the hospice philosophy mirrors a lot of what is in this act in terms of choice, client and consumer choice, and the type of services they're getting, and the idea that people like to receive services in their own homes wherever possible, as opposed to institutional care.

Hospice care is provided primarily by volunteers, which is certainly a plus, I think, to the entire health care and long-term care system.

Most of our hospice programs provide care to people regardless of diagnosis, although some of them are for people living with cancer specifically and Casey House, of course, is specifically for people living with AIDS.

The concerns I would like to talk to you about tonight are basically some concerns that we have had in the hospice field in response to some of the things we have seen coming out in redirections in long-term care and some of the discussion and information that has come out in terms of the development of multiservice agencies.

I think one of our major concerns right from the beginning is the fact that hospice and palliative care is sort of on the fringes; it's not really mentioned in the act. However, we're getting mixed messages in terms of how hospice is going to be provided in long-term care. We get some messages that say, "Oh yes, you will be a part of the MSA." Sometimes we hear: "Oh no, you're not a part of the MSA. You will be a satellite program that will be offering care as a distinct separate part from an MSA." So there's some confusion about how really do we fit into the system, and I think a lot of that is because of our timing.

We at the provincial organization receive no government funding at all. We pay for our services through donations and some very small hospice member fees that our agencies pay towards us. Our hospice programs have recently started to receive some government funding. It's a small percentage of their budget and I think one of the challenges we've seen is the fact that that's really just started in this last year. March and April 1994 were the first months that we were starting to see some of the funding flow through from the government's palliative care initiative, which was announced in December 1992.

In a way, that's been wonderful for us in terms of having some support for some of the services that we're offering, but at the same time it's been a real challenge because nobody knows quite where we fit: Do we really fit with the redirections in long-term care? Because we've not been there before. We've had some struggles in trying to follow the information that comes out.

Just to give you an example, in some of the information it says, "You will, of course, still be expected to raise the 30% money from the community that you raise now." Well, of course with hospices the 30-70 split means nothing. Many of them still raise all of their own money themselves, and for those that do get government funding it certainly isn't a 30-70 split. So in many ways we're having real difficulty trying to work our way through the system and keep up with what's coming out to us in terms of changes in MSAs and redirections in long-term care.

We have a concern about volunteers. As I listened to the presentation previous to me this evening, I think there are a couple of areas where we probably share some concerns. As I mentioned earlier, hospice is almost primarily care provided by volunteers. Most of our hospice programs, if they have any staff at all, may have one less-than-full-time staff person whose role is to coordinate the services, to recruit and orient volunteers, to train them, to supervise and then to coordinate their care with the other care providers who are from our partners, from the medical and nursing community, homemaking agencies, who will also be providing care to people in their own homes. So there's a question as to what will happen with those volunteers.

There's a lot of fear about: "What does the MSA mean for my volunteer program, my hospice that is primarily volunteers? Are they still going to come and work from my hospice when it's no longer there if in fact it's going to be a part of an MSA structure?"

Fund-raising obviously is very much a concern for us when that's primarily how we pay for our services. We've tried to ask questions as we go along in terms of what does it mean for us. If we're a part of an MSA that no longer has a board of directors who will raise the funds to run the hospice program, because of course at this point the board plays a very major fund-raising role in terms of raising the funds to keep the hospice organization going -- that's been very difficult, again, in reading the information that's coming out, trying to figure out where the funding for our hospice programs will come from.

A fourth concern that we have, which I think can be demonstrated as a real one, is the lack of knowledge about hospice care. Obviously, that's partly because we are such a new organization and a new field of service in Ontario; also because we simply haven't had the time or the resources to do the public awareness that we need to do. When you're trying to raise funds to provide the service that you provide, it's very difficult to also be trying to do a lot of public awareness at the same time.

We have concerns about that for a couple of reasons. If we are going to be a part of redirections in long-term care in the MSA structure, will decisions be made on how hospice fits into that, with full knowledge of what it is that hospice does, and what hospice services are and how they fit into the other care providers in the community? We have some concern that if decisions are made without full knowledge of how hospice works, is it really going to be made in the best interests of the clients we're serving at this point?

Another concern we have is simply to do with research about the benefit, both human and cost benefit of course, of hospice care. We certainly have not had the time or the resources to do a lot of research into the kinds of care that we're providing in terms of the benefit costwise and also the benefit humanwise.

We believe that people prefer to be at home and that we're providing good care, but we've not had the resources to determine, is that in fact a more cost-effective form of care than institutional care? We believe it is, but we don't have the facts and the figures to back that up and we believe that's something that has to be looked at very seriously in terms of long-term care in the future: some research into hospice forms of care and how they fit into the system in terms of cost as well as in terms of the types of services that are provided.

Having said that, and mentioning those as the concerns that we have in the hospice field, we have come up with some recommendations that we feel are appropriate for looking at how does this fit with long-term care changes.

Number one -- and this is in the written brief that I have passed around, but just to highlight -- we feel that there needs to be some research on the cost benefit of hospice programs. Unless there's some research into, is this a good idea moneywise, fundingwise and in terms of what kind of care people are getting, then how can we continue to grow the way we are? I think simply the growth in demand for services is a statement that people prefer hospice care, but I think there needs to be some research done into that.

We have a concern that hospice and palliative care are not adequately available across the province for people who need it. I know the Ontario Palliative Care Association was a presenter here earlier this afternoon. Being in similar fields, we do cooperate a lot in terms of trying to promote hospice and palliative care and we share the belief that there are not enough people having access to proper hospice and palliative care in the province, partly because it's not well known, people don't realize it's an option for them, but also because it's not been funded to the extent that it's available for all the people who need it.


Another concern we have is related to that in terms of distance. Do people in the north have appropriate access to hospice and palliative care? I think the answer to that is no. For other types of groups -- different language groups, different cultural groups -- we know that even though hospice and palliative care is sadly lacking in the amount of services available, it's even more difficult for people from those special groups to access hospice care.

Another concern we have is the fact that we do have a provincial association that has been established by hospices, that is funded by hospices and fund-raising, and we have a lot of information on hospice care. What's out there now? What's being provided now? Where are new groups springing up? What are hospices doing and where are they? In what 60 communities in the province do we have hospices?

That kind of information could be accessed through our association and, to my knowledge, that's not been used all that well in the development of the MSA model. Certainly we were very much involved in the discussions around the palliative care initiative that was announced in December 1992, but since that time we've had great difficulty in trying to provide information to the people who are making the decisions in terms of the MSA structures and how hospice will or will not be affected by that.

Our final recommendation is that district health councils and others who are involved in planning the MSAs and long-term care reform do access those of us who do know about what's going on with hospice in the province so that we can work together to come up with whatever is the best possible, accessible service for those people who need hospice and palliative care in the long-term care structure. With that, I'd like to stop for some questions.

Ms Carter: I know that in principle the government is committed to hospice care, and we have in fact put extra funds into palliative care. Of course the whole intent of the act we have here is to encourage home care and keeping people in the community as opposed to institutional care, so obviously we're with you on that as well. Also, we want services to be available all over the province, and obviously your service is spreading, but it isn't province-wide at the moment.

For your answer as to how this fits in with the MSAs and how funds will be raised, I think perhaps we should ask the ministry adviser if he would fill us in on that.

Mr Wessenger: Yes. I will ask the policy adviser to provide some clarification with respect to palliative care and the funding aspects.

Mr Quirt: As was pointed out by our presenter, the government announced I think it's $4.8 million in annual funding to support palliative care initiatives across the province, and that's really divided into three programs.

There's an initiative to provide some training to a member of staff from each long-term care facility in the province and each community services agency each year in palliative care. There's an initiative to provide training to physicians across the province in palliative care as well. In addition, we'll be establishing 14 pain and symptom control teams, which will be a mechanism really to coordinate professional input from physicians and nurses and other people specializing in pain control to make that expertise available to our long-term care system.

Thirdly, we're supporting financially the volunteer visiting hospice programs that have been presented about this evening. That is a very modest amount of money that we're providing to those groups. To date, they hadn't been supported by government, and I believe this is the first time that about 50, if I'm not mistaken, groups will receive some funding support.

That funding support I suspect will assist in just what has been described as the recruitment and training of volunteers. By all means we'd like to see that continue, and I think it would be important for those local hospice groups to be in the decisions about the multiservice agency. It's conceivable that the resources of a multiservice agency could expand that training and support so that even more volunteers are involved in that type of work.

The example was given that some programs don't receive government funding. Clearly it's up to them, then, whether they'd like to have some affiliation with the MSA or continue to go it alone. It's conceivable that the local planning would decide that, "Heck, it's just as simple to continue to provide this grant directly to the group of volunteers and let them continue to do their good work." I think that's quite flexible in providing that modest amount of support.

I would hope the creation of MSAs and the cooperation between MSAs and the visiting hospice programs now will result in more attention to this service and more support in a coordinated way by the existing long-term care resources to the volunteers that are out there doing those visits and that support the people in their last days.

The Vice-Chair: Do you have any response?

Ms Balfour: No, except to say that's exactly the funding that I was speaking of earlier, the palliative care initiative, from which we did receive almost $500,000, I believe, in the first year for a number of different hospice organizations, and we certainly do appreciate that. Again, it was simply unclear as to how that palliative care initiative fits along with the MSA structure in the future.

Ms Carter: Perhaps the answer is that your group should get involved with the long-term care committees in the regions where they operate, and be part of what is happening.

Ms Balfour: We've certainly tried to do that. Again, I think it's partly because there's not a lot of understanding about what hospice is, what hospice does. I know that in some areas the long-term care committees are very restricted in terms of how many people can be involved, and because hospice is new and small and not seen as an equal player sometimes, sometimes it's difficult to do that.

Mr Quirt: I would recommend that you approach the DHC directly and say, "Hey, we've got a presentation for your long-term care subcommittee on an important program."

Mr McGuinty: Thank you very much for your presentation. I know that some of our members have received your newsletter in the past and have complimented your organization on its quality. I want to at the outset congratulate you on -- this is something obviously that's pure gold. We've got an organization here that doesn't receive any government funding and has grown to the point where it's delivering 60 hospice programs. Everything's done by volunteers, I assume, primarily?

Mr Wessenger: Just on a point of clarification or a point of order: I think it was clear that there is some government funding to the --

Ms Balfour: Let me clarify: There's no government funding to the provincial association. We operate totally clear of government funding. Our hospice members who are distinct and separate bodies who belong to our organization do receive government funding.

Mr Wessenger: Right.

Mr McGuinty: No, I was making reference to the association.

Unless I missed it, what I want from you is your opinion as to how this legislation we're talking about is going to affect me as a consumer. Let's say I was in need of the kind of program which your members offer. Is this going to improve that kind of care, is it going to have a neutral effect or is it going to have a negative impact?

Ms Balfour: I think that depends totally on how it's structured. There are some benefits to this. Certainly, we see that with some government funding we're going to be able to serve a lot more people than we've been able to serve in the past. That's obviously going to make a big difference for us. If people are able to keep the essence of hospice care in terms of who are the clients and how do they reach the clients and can they still provide the same quality and level of service to families and clients in an MSA structure, I think then it will work fine.

The fear right now is there's not a lot of knowledge on how it's going to work. Am I going to be able to keep my volunteers? Who's going to do my fund-raising? Who's going to replace my board in that fund-raising role if the board no longer exists? Who will be planning the policy that the board now plans? Those are the concerns that hospice people have, and if those are addressed in a way that, as I say, allows us to keep the essence of what it is that we provide, I think it could work very well.


Mr McGuinty: How important a factor is the volunteer component among your members?

Ms Balfour: Oh, extremely. As I was saying, most of our programs are primarily volunteers. We collect annual statistics and our statistics for the last year show us that 95% of the people who work in hospice in Ontario are volunteers; only 5% are staff people. So it's absolutely crucial. We wouldn't have a hospice movement without them.

Mr McGuinty: You can't run much cheaper than that, can you?

Ms Balfour: Not much.

Mr McGuinty: Will those volunteers work for a multiservice agency?

Ms Balfour: That's the question. I think it's how it's presented to them. We have volunteers, of course, who have thrown up their hands and said: "I work for a hospice. I'm not going to volunteer my time for some big multiservice agency." So I think no matter what happens, if hospice was to be part of an MSA, yes, we would lose some, but it depends on how it's approached. If people are still able to volunteer for a hospice program, then I think we may be able to keep them, as long as it's not seen as, "No, you have to volunteer for this big MSA."


The Vice-Chair: The next presentation will be by representatives of the Ontario Home Care Case Managers' Association. Welcome to the committee. Please introduce yourselves and proceed with your presentation when you're ready.

Ms Marg Kovacs: Thank you, Mr Chairman, ladies and gentlemen. My name is Marg Kovacs, and I'm a case manager with the Hamilton-Wentworth Home Care Program. My background includes home care case management and psychiatric case management, and I'm the immediate past president of the Ontario Home Care Case Managers' Association. With me is Margaret Chiles, a case manager with the Metro Toronto Home Care Program and our president; and Caroline Read, the case manager with the Waterloo Region Home Care Program and our vice-president.

The Ontario Home Care Case Managers' Association is a professional organization. It is six years new and it represents approximately 1,700 case managers who work for the 38 home care programs in Ontario.

Our association is the recognized voice of the Ontario home care case managers. We provide resources to case managers. We promote and develop the role, function and practice of case management and we are committed to partnerships which promote quality service provision.

Certainly over the last few years case managers have seen that there is a massive change and a massive increase in the need for services in the community. The Metro Toronto Home Care Program in 1992-93 admitted 31,280 clients to their acute home care program. That is one of the three programs that they would administer. In 1993-94 the numbers have virtually doubled. In 1992-93 Metro Toronto had about 9,000 registered clients on any given day. In 1993-94 they have approximately 15,000 registered clients on any given day. Social workers do not see little old ladies looking at placement issues any more; social workers are dealing with abuse issues that arise from stresses on families trying to provide care to their family members.

We certainly support this act and recognize that the time for change is here. We applaud Bill 173 in principle. Finally, the ministry has seen fit to embrace a principle that case managers have been practising by for many years. Case management has always focused on the consumer. Case managers utilize a client-centred approach to service delivery, and we have done so for hundreds of thousands of home care clients of all ages who have received home care services for almost 30 years in this province. We will continue to practise in a client-centred manner.

On any given day over 65,000 Ontario citizens are in receipt of client-centred services through the home care programs. What makes home care services client-directed? It's quite simple. We are guests in our clients' homes. We cannot proceed any faster; we cannot introduce services any faster than a client or a client's family is prepared to accept at that time.

How do we as case managers manage this? We start with a comprehensive, holistic assessment of needs, taking into account the client's strengths, and many clients and families do not recognize the strengths that they have. Case managers draw on their health care or their health professional background knowledge base to ensure that the client's strengths or their level of wellness is maintained, and this is done by providing intervention based on assessed needs.

The case management outcome is the right service to the right client at the right time in the right place. I'll give you an example to illustrate this. I've just recently become aware of an 83-year-old lady who is in receipt of home care services. She has nursing and homemaking for a chronic respiratory condition. Over the last couple of months, her respiratory condition has exacerbated to the point where she can no longer go out for groceries.

This is really a big issue to this lady. She does not see that asking family to grocery-shop is the answer to her problem. When the case manager was making the reassessment visit, the client's solution is, "I will ask for an additional three hours of homemaking for the homemaker to go and do my groceries," and it's $17 an hour for homemaking. That's a pretty expensive taxpayer service.

The case manager was able to negotiate with the client and make the client aware of a volunteer-based grocery shopping service in her community which will take the client's list, go to the grocery store of her choice and get the groceries. The grocery shopping will be done on a day that the homemaker is visiting, so the homemaker can assist the client in putting the groceries away and starting some meal preparation.

That reassessment ensured that the client's integrity was maintained, that the new needs were identified and they were met without an undue burden on human or financial resources. Assessment and reassessment by case managers have a major impact on the outcomes of a client's feeling of wellness and service utilization.

The role of the case manager is not well understood in the delivery of health and social services, and it is undervalued. Karen Goldenberg, the special adviser for MSA implementation, acknowledged that "of all the misconceptions and inaccuracies that arose during the long-term care consultation...the role of the home care case manager was least understood." She stated later on that case management was an essential function that was played by the home care case managers and would continue to be played in the multiservice agency.

The ministry's previous documents on long-term care included case management as an acknowledged core function and service of the multiservice agency, but now Bill 173 has come out and there is no mention of case management anywhere.

Section 2 of the act lists four types of services as the mandatory basket. They are community support, homemaking, personal support and professional services. Case management is a professional service and it is provided by health care professionals who are dedicated to that role with dedicated time. It is not a role that can share time with that of direct, hands-on service provision. It's far too time-intensive.

There are six key functions of case management: a holistic assessment, service planning, service coordination, resource management, reassessment and alternative planning for changing needs or on discharge, and these case management functions ensure that there is a consistent accountability. The buck stops with me, the case manager. There is a decrease in fragmentation of services and there is a decrease in inappropriate service utilization.

The core functions, skills, knowledge and experience of case managers receive lipservice from the ministry, and yet the vital role of case management has been acknowledged and included by the ministry in previous long-term care documents. The ministry has embraced the case management principle of client-directed services in this legislation. The ministry must embrace the role of case manager in this legislation.


Ms Caroline Read: I would like to make some summary comments and some recommendations on behalf of the Ontario Home Care Case Managers' Association.

We acknowledge the need for philosophical and practical system changes.

We remind the ministry that the expertise, the skill, the mandate and the knowledge base required for assessment and service coordination currently exists in 1,700 practising home care case managers. At this table the three of us have almost 70 years of community service, many of those in home care programs and case management delivery.

We would like to see the assurance for citizens of this province, as the home care case managers embrace already, that consumer rights to participate and decide service plan needs is the essence of the current case management practice; that indeed it is client-centred, that it is goal-oriented, that it is multidisciplinary in its approach; and that service coordination is actually only one component of case management.

The association suggests that previous system-based restrictions led to decreased consumer lack of control and input and the current misunderstanding of the value of case management. We would like the ministry to acknowledge the need to better inform our consumers about the functions and not get hung up on a name.

The association acknowledges that this province is unique in its population, its size, its geography and its resource extremes, and the need to ensure that local district health councils provide direction and facilitation pertinent to the community's needs and resources is paramount, thereby increasing the equitable service across the province while allowing sufficient flexibility to meet local diversities and needs.

The association requests that the ministry acknowledge that case management, as a model of service delivery, is valued throughout the world and must be included in the Long-Term Care Act. We would point out to this committee that case management, internationally, is really growing at an alarming rate in terms of its acceptability, its practice, its research.

In Toronto this September there is an international conference on long-term care case management. Canada, the United States, England, South Africa, Israel, Australia and New Zealand are all presenting at this international conference, where case management is the focus.

Nationally, the Canadian Home Care Association has submitted proposals for research projects on case management. Case management in the United States is far ahead of Canada, and it is really only in the last six to eight years that case managers working in home care programs have felt empowered and found their personal volunteer time to pursue the practice of case management and to promote it.

We would like to recommend to this committee:

-- That decision-making be based on both public response and serious consideration of research-based data and evaluation. It is our concern that much of the input in terms of public response has been purely anecdotal, and to this point in time there has been very little Canadian research done on case management. We would just caution that the ministry not throw the baby out with the bathwater;

-- That case management be designated in the legislation as a core function and be delegated only with caution in specific consumer need and service situations; that there are appropriate places and times for single-service case management and for consumer case management; that the current case managers are also aware of those very existences but have not had the flexibility, because of legislative strictures, to provide that flexibility to the consumer;

-- That designated case managers are identified to ensure consistency in screening and assessment, knowledge of resources -- I would just share with you that in Waterloo region alone, where I practise, there are over 1,000 community resources which case managers are fairly well informed about and share with their clients -- consumer access to resources, service coordination expertise, and evaluation skills;

Therefore providing the very accountability that the ministry seeks.

The case managers' association is pleased to have had the opportunity to address this committee and we trust that you will seriously consider our recommendations and our concerns, and we would be happy to entertain any questions.

Mr Wessenger: Thank you very much for your presentation. I note your concerns about the function being set out in the bill, and I'm advised that section 20, which you should refer to, sets out the function that makes it in fact the obligation of every approved agency in effect to assess a person's requirements, determine the person's eligibility and develop a plan of service. I suggest that that really sets out as a core, as a requirement of every approved agency, so in effect case management is set out as a core obligation of every approved agency.

Ms Margaret Chiles: If I could respond to that, it identifies the functions of case management, but it doesn't identify that it is a case manager who does it. It's up to the MSA to decide who would do it, and without any direction as to who will be doing that function of case management, you could end up with the cleaner doing it.

Mr Wessenger: I think I'll ask our policy adviser to respond to that comment.

Mr Quirt: It certainly isn't our intention that the cleaners would end up doing the case management and I think, as you've pointed out, that the bill does try to reflect the importance of the assessment of individuals' needs and the development of an appropriate service plan involving the client, and the monitoring of the effectiveness of that service plan and the development of alternative strategies if those original strategies don't work.

May I also point out that the experience and skills of the home care case managers across the province may be regarded as perhaps one of the most important building blocks for the new system. So in no way are we trying to imply by not mentioning case management specifically in the bill that those services aren't a necessary and important part of the new MSA system and that the people who do it now aren't an extremely valuable resource that we need in the new system.

The potential is there, however, that for the MSA to organize its service delivery activities in a way where the appropriate professionals involved at the right time to do assessment -- it's conceivable that for some clients the case management assessment might be a very short assessment process. If someone just needs a ride to the doctor, it may be a very short conversation and a volunteer dispatched. In other cases it might be appropriate that a social worker who had familiarity with the particular social needs of a particular client might assume the case management responsibility for that client.

We know the background of our home care case managers is almost exclusively a nursing background, and that's a very important set of skills and background for that job as well. We haven't ruled out the possibility that in some MSAs a worker may have, in addition to case management responsibilities, some direct service provision responsibilities as well. We're not saying that you can't do that. We're saying that probably both models might be tried, and it might vary on the basis of geography, for example, how best those services might be configured.

I know some of our staff said, "Well, where's the term `case management' in the bill?" and we ran into the issue of the difficulty of defining what case management is for a variety of different clients. I think you've pointed out quite rightly that the bill doesn't give the reader the correct impression, because the bill, to a reader not familiar with our intentions, might imply that we don't think case management's an important service in its own right. We know that it is, and the presenter just before you talked about how intensive case management can be the difference between someone staying at home and having to go to a facility.

I think we're on the same wavelength. I think it's a question of making sure that the wording of the bill reflects their intentions. Certainly the skills that you people contribute to the system are recognized and we need you as an ongoing part of it.


Ms Read: I thank you for that acknowledgement. It's important, too, to remember that there is a tremendous growth in the acceptance of case management. Much of what is misunderstood about case management has been due to lack of resources to inform the consumers.

At this point in time, as we're about to change much of our system in terms of access for certain -- I think it's very important that we also share with the public the functions that the MSA provides and explain those functions and terms to them. I would hope the ministry is planning to provide the financial resources to inform our clientele. It's pure folly to think that they would be any better informed with a new system than they are presently without that kind of information sharing.

Mr Quirt: We recognize that information provided to the client in an understandable way is a difficult thing to achieve, and it's an important service that we'd like to improve on. Part of the problem with the existing system is that with the fragmentation of the system and the variety of different workers and agencies sometimes involved, it's sometimes difficult for one worker to really understand what all those other agencies are involved in, and it's sometimes difficult to have a coordinated approach among a number of workers if their mandates are a little different or if the provincial rules are a little different.

You would probably agree with my perception that the role of home care case managers has been constrained more by provincial policy and restrictions than it has been by the willingness or the skills of the workers out there doing the job. What we're trying to achieve with the multiservice agency concept is the freedom for an interdisciplinary approach to services so that you can sit around the table with your colleagues and decide how your agency can best respond to somebody's needs, rather than being on the phone to four other agencies to try to figure that out.

Mrs Sullivan: I heard this afternoon I think the parliamentary assistant or counsel refer to section 20 of the act as the case management vehicle, because this has been raised in another presentation. I note that you indicate case management should be included in the list of professional services. My concern, on re-reading section 20, is that section 20 describes a series of tasks that don't imply an integrated case management function. In fact, it really only describes, first of all, the assessment and eligibility, which may or may not include a clinical assessment. It doesn't even give an indication of what has to be assessed and what the eligibility criteria are. We know those eligibility criteria are going to be developed through the regulations, which somebody will see some time.

The other thing I think is of concern is the structure of the bill itself, because we have, first of all, the definitions of the items that are community services. Then we have, in another couple of sections further back, a description of the multiservice agencies. Nowhere in the description of the MSAs is the role of the case manager described or the functions of determining eligibility or assessment and so on. There is an indication that the minister may designate an approved agency as an MSA.

Then we move to section 20 and we find that the case management function applies to an approved agency, which may or may not be an MSA. Maybe counsel should look at this. Are all approved agencies MSAs? If they're not, is this only the transition period? If this is only for the transition period, then the whole point about section 20 being the case management issue is moot, because then it doesn't exist for the MSA. Do you hear what I'm saying?

Mr Wessenger: I think I'll ask counsel to respond to that.

Ms Czukar: There are really two points in relation to that. One is yes, partly it's to accommodate the transition period that the requirement is imposed upon approved agencies, so that those agencies which currently provide the case management function can continue to do it under the bill, but also to impose a requirement on every approved agency to do this, to assess people's needs, to come up with a plan, to involve the person in developing a plan, to reassess needs as required and to implement changes in the plan when required. So it's a flexible provision. Most of the provisions in the bill are flexible in order to accommodate both the existing system, the transition to the new system and a flexible new system. That's why it is where it is.

Mrs Sullivan: Maybe it should be improved.

Mr Jim Wilson: I would concur with Mrs Sullivan that it is extremely confusing, the way the bill is written. It's almost laughable if it wasn't such a serious topic.

I want to thank the group for its presentation. You've brought forward some points that needed to be said, because the key to this whole thing, as far as I can tell, is assessment. I'm going to try again here to get a clarification from the government. The way the bill is written, clause 20(1)(a), the very first thing, of course, that has to be done is to assess the person's requirements. It's the key to everything, yet it's very unclear to me -- and I've been Health critic for four years and seen lots of legislation that's unclear, and here we are again -- as to what the heck you mean by that. Who's going to do the assessment? I understand it's about a 23- to 26-page assessment document at the moment, which I hope you whittle down to something more reasonable.

Here are some clear questions: Is it going to be up to each MSA or are there going to be provincial standards on who fills out the 23-page document? What type of professional or otherwise will be required to do that? Back to who. Really, don't tell me this is all going in regulations, because my caucus just may have to remove ourselves from this bill, which would close down the hearings, waiting for your regulations, because I'm not voting on another piece of legislation around here where I don't know what I'm voting on.

Mr Wessenger: I am going to refer that to a policy adviser, but I can assure you there's no 23-page assessment form to be filled out.

Mr Jim Wilson: That's what somebody on the committee -- that's someone on your own committee.

Mr Wessenger: No, there's no such assessment form.

Mr Jim Wilson: It was 26; we're down to 23.

Mr Wessenger: No, no such assessment form, I can assure you that.

Interjection: Thirty-five?

Mr Jim Wilson: Oh, it was 35? Maybe you should talk to the committee members I met with at lunchtime.

Mr Quirt: Let me first of all point out that there's no consensus among the community providers that we're consulting with on whether in fact there should be one provincial standard assessment form. There is a consensus, I think it's fair to say, that there should be a consistent assessment process or approach, because the community providers' coalition acknowledges the need for the new system to treat people fairly, so that if you were assessed for a range of programs and services in Kingston and moved to Oshawa, you wouldn't all of a sudden not be eligible for something, or be eligible for a whole bunch of things one place you wouldn't be somewhere else. Determining who's eligible for how much requires people to ask similar questions so that a fair identification of their needs can be made one place to the next.

We were under the impression that a number of people felt that one consistent assessment form was a good idea. We certainly proposed a work group to take a look at a form that's been in existence since about 1989 or 1990, developed by the office for senior citizens and somewhat improved since then. Our advisers have cautioned us that no, maybe a consistent form isn't necessary, that perhaps just consistent service definitions and consistent data gathered and consistent topics covered in an assessment process might be an adequate set of tools to ensure fairness and consistency in what people are eligible for. So we'll continue that work. That work's under way now with our advisers.


Who does the assessment? That would vary in accordance with the type of service that someone requires. For example, if someone was to call the intake worker at an MSA and say: "Hey, I understand you've got volunteers who provide rides; I need to go to the doctor next Thursday," then it may well be that a 30-second conversation is necessary to dispatch a volunteer and that's the end of it, and the assessment information would simply say, "Mrs Smith, on such-and-such a street needs a pickup," and that would be the end of it. The assessment form that had been developed, and it's under discussion now, was certainly very modular in its approach so that for some clients you'd never get by the first five lines on the first page.

For others, for example, who had a more complicated range of needs, it may be an assessment that's done by a specialized nurse who is aware of the best approach to intravenous pain control in the home, for example, and there would be a very in-depth assessment that would be done collaboratively with a physician and a nurse to determine how best medication might be provided to that client, and it would be quite an involved assessment that may involve a multidisciplinary approach.

The form, as I understand it, is not 23 or 25 or 27 or whatever pages long; there's a policy paper, a discussion paper about assessment and intake and questions, that's probably about that length, but I don't think the form itself is that long. I stand to be corrected, but I'm advised it's not that long.

As I said earlier, we may not have a consistent form, because when we talked to people from the Ontario Community Support Association and from the Ontario Home Care Programs Association and from Saint Elizabeth's and from other community organizations, the VON, for example, they're cautioning us, "No, you don't have to be that prescriptive to say one form is necessary." So we continue to meet with these folks to talk about eligibility criteria and their relationship to what information you need to make a decision, what type of process happens within an MSA with the intake worker, and then, when it is referred to a case manager who really has to apply his or her professional skills to develop the most appropriate service response, and whether we end up with a consistent form or not is an open question at this point. The only way we'd end up with a consistent form is if there was a consensus among our partners that said, "Yes, this is a good idea."

Ms Read: Perhaps I might just make a couple of comments around assessment, please.

I think we would agree, as case managers, that there is a place for screening and there is a place for assessment. Certainly, when a caller calls in to an MSA, if they request a ride to their doctor's, that is definitely something that can be handled through a screening contact. However, there is an assumption that for most people calling in to the MSA, from what I have read in the documents, the individuals will know what it is they need and they would ask for nursing or they would ask for homemaking. I think that's a false assumption. It takes very skilled case management to determine, through a holistic assessment, exactly what the need is.

A frail elderly senior who lives alone who contacts us because they're having difficulty lifting the vacuum cleaner -- and this happens regularly -- may in fact have many more problems, and that is really the tip of the iceberg. They just know they're not coping any more. It is only since the integrated homemaker program came along that we have had the ability to assess, by virtue of the lack for a physician referral requirement.

Now this particular lady, and I am thinking of a particular case, was an accident waiting to happen. We did go out and do a home assessment. She in fact had scatter rugs throughout her house. She lived in an old two-storey with a bathroom on the upper level only. She was not able to cope, and it was only through a very detailed OT assessment that we were able to make some modifications in her home to help her manage in a very appropriate manner for a considerable length of time.

My point here is that case management is able to determine those needs because of their highly skilled assessment, and that not everyone is able to do that. Not only that, but we do not have a disease focus, as many of the single-discipline providers do.

In terms of a standardized assessment tool, a number of years ago we were working on a one-stop access tool. It seems to me that the ISQ has not moved terribly far away from that and we are still looking at an extremely lengthy document.

The other thing I would like to say is that we acknowledge that consumers do not wish multiassessments. We feel, as case managers, that we have assessed people to death, and we would love to see something that minimizes the need for overassessing.

However, there is always the place for the single-service provider whose area of expertise is very definite. I am not going to go in to do an assessment and ask them what their range of motion is in their extremities; however, a physiotherapist or an occupational therapist may well do that. So there is a place for the specific beyond the holistic, generalized assessment.

It's really important for us to remember that hands-on service providers already have waiting lists. We are expecting them now to add to their tasks case management functions. We are also expecting them to be available and accessible to the consumer if they are a single-service provider. I'm not clear, from the documents we have received, how that is going to happen. We don't want to suggest that it cannot be done, but we do not see what the process is going to be in developing that single-service provision.

We're also concerned about passing the baton of case management, if you will, as a client's needs change. We often start with the acknowledgement that there is a single service need, and we provide the service to meet that need. But after that person has been reassessed in their home environment following a hospital discharge, in that environment we can see other needs that must be met, and then we pass along to the physician the request for additional service and other service providers become involved. Do we pass the case management baton from one provider to the other? When all of our goals are met, do we pass it along then to the homemaking or to the personal support? It is very confusing in this document.

Mr Quirt: I can appreciate the confusion you've expressed. You've made a very articulate argument in favour of the benefits of case management, and I agree with what you've said. I was certainly only trying to point out that the assessment of an individual client might range from a very brief discussion about a single service to a more complex, in-depth assessment involving the professionals to which you've referred. One of the benefits that advocates of the multiservice agency see is the benefit of that multidisciplinary team working more collaboratively, closer together, without the issue of, "When do I pass on lead responsibility from one agency to another?"

You've talked about the multiplicity of assessments. I think you'd have to agree that some clients express frustration from time to time if in fact they're assessed by a home care case manager and you decide it's appropriate that a physiotherapist and a nurse and a homemaker visit. It's conceivable that three different agencies are going to go out and see the person you've assessed, and it's conceivable and understandable that each of those other three agencies is going to have to, even with your best efforts to inform them about the needs of the client, do their own form of assessment once they get there.

We think putting professionals with good intentions together in a team in a multiservice agency-multidisciplinary setting allows you to collaborate better, understand your client collectively better and deliver a better multidisciplinary service as a result.

Ms Read: Perhaps I live in a very fortunate area. I think in my own program we practise that way now. We are not all under one roof. We do case conference, and that is one of the tools case managers use, and we do meet and talk on a regular basis and receive written reports when there is a status change. I think we already do look at the multidisciplinary team approach and we do share those reassessments by the provider.

Mr Quirt: I don't think we have a disagreement, then.



The Vice-Chair: Next is the East York Health Unit. Welcome to the committee.

Mr Michael Prue: My name is Michael Prue. I'm the mayor of East York, and I'm here today with the medical officer of health, Dr Sheela Basrur, and Pat Thomas, the director of adult health, and Janice Leet, a community health nurse.

I'd like to commend the committee and the staff, and perhaps the government, on finally taking some action on this. I was reminding myself today that more than 25 years ago I used to come down to the Legislature when I was a student at the University of Toronto, and I heard many passionate debates on the need to reform health care, particularly for the aged. I hope somebody's finally going to get to it, sooner or later, some day, somehow. This is the best attempt I've seen as a watcher for more than 25 years.

A little bit about the demographics of East York. It's one of Canada's oldest communities; next to Victoria in British Columbia, we are considered to be the oldest community. We're the home of some eight seniors' homes, and the average age is among Canada's oldest. We feel that the future for most of Ontario is already in East York. As the population ages, as people live longer, as the housing stock and everything that is Canada continues to happen, it's only a matter of time till other communities have 16% to 25% of population over age 65.

East York has embraced Bill 173, and we have tried as best we can to work along with the government and those who are supportive of long-term health care reform to give it a community focus. We believe we have the kind of experience and the kind of knowhow in East York that will make it work. We welcome the initiative, and I have spoken publicly at Metro council in opposition to those who think this bill is not the way to go.

We believe that dealing with the elderly is something that must be done and must be done very quickly because (1) it's getting very expensive and (2) we don't believe the level of service is as high or as qualitative as it could be.

We have attempted in East York to have one-stop shopping, which this bill proposes to do, and I can see that some of the people are looking at the brochure we have produced through the health unit. There's one-stop shopping, or actually two-stop shopping. We have two major locations that hand out this information: the Neighbourhood Information Centre, which is in the easterly part of East York, and the Thorncliffe Neighbourhood Office, which services the westerly portion. People can go there and get some kind of referral or an idea, with someone to assist them, in looking at all these agencies and what they can do.

The borough of East York has also been very instrumental in setting up what we call a community action team, CAT for short. This is a team of health care providers, the police, public health officials, community development council representatives, Community Care East York representatives for the elderly, who can and will go out to homes where there's an identified problem, whether the problem be abuse or alcoholism or just a house in a run-down condition, and go out and make the necessary recommendations to council or to the appropriate agency to deal with it.

We feel we've had a great deal of success, and we are here to support the bill, with some modifications -- always with some modifications. I'm going to turn it over to Dr Basrur, who's really the expert in this, to talk about the modifications. They are in two areas: one is dental and -- the second one won't come to me, but she'll do it right away.

Dr Sheela Basrur: You'll remember it in a very quick second. I'll briefly walk the committee through the recommendations, which are on the preface page. Some of these have already been addressed in preceding deputations, so I won't go over them in detail.

The first is a plea that the regulations governing eligibility criteria, client assessment, service delivery and additional services of any sort provide flexibility and room for interpretation because of the diversity of needs that we see in the community. An example of the diversity will be described shortly in a typical scenario that we often face.

Recommendation 2 really pertains to the programs you've heard reference to, called client intervention and assistance, or CIA, programs. I didn't mention them specifically in the brief because I felt this was a program funded exclusively in Metro Toronto up until now, and I wasn't certain if the committee's mandate was to look at province-wide application or whether you would be able to look at local variations. We would make a very strong plea that client invention and assistance programs continue to be funded and, if anything, expanded across the province, if that's possible.

I've heard support for CIA being implicit in sections 20 and 21. I've not heard whether the funding that's currently given to Metro will remain in the system for the same purpose, and we request clarification of that.

The final recommendation regards the addition to professional services of basic dental care. We'll describe in some detail what it's like for seniors in the community who have absolutely no access to dental care and what it might be like if they had some.

Let me also make the point that the health unit is here truly as a neutral third-party observer, and we're in the unusual position of asking to give up some of the work we're currently doing. We feel that some of the work we're doing in the area of seniors is better done by an MSA, and rather than us continuing to work on the fringes, we think the MSA ought to really be one-stop shopping for everything in a full, diverse range of needs, and not to have public health, at least in East York, continuing to dabble at the fringes for lack of another provider to step in and fill the breach.

If you would turn to the bottom of page 2, I have outlined one of the situations that has been at the forefront of our minds over the last couple of years. The committee may recall the widely publicized death of an elderly woman -- her name was widely published; it was Muriel Smith -- who was found dead in her house with claims of no heat, no water, no hydro, no food, and terrible, terrible living conditions: garbage and excrement and old food and bags piled to the ceiling in every room, if one could even gain access from one room to the next. Her body was found in the house a few weeks after she had died -- very, very terrible conditions, and it caused a tremendous level of concern in the community.

It was a political problem. It was a community problem. It was an organizational, administrative, legal problem for all the agencies that had been involved with her. That included the health unit, other community support agencies, the police, the fire department, bylaw -- you name it. People had been in and out of her house, or at least her yard, for years, and no one had been in a position to prevent her death. Whether it was preventable or not, we'll never know, but it wasn't for lack of trying, and yet this person still died.

We've been asking ourselves since that time, was there something that was missing in the current system that could be provided through an MSA? If there is, let's identify that and please make sure it's in the reformed long-term care system so we don't have more of these people happening.

I guess our concern is that these aren't isolated cases; we saw the tip of the iceberg in that one instance. Ever since that awareness has been heightened, we've been getting call after call after call from concerned neighbours, concerned family members, from police, hydro workers, Consumers' Gas, anyone who goes into a house and sees a person living in very terrible conditions and says: "Oh, my goodness, this person could die before I get back in the next time. I'd better phone somebody. Who do I call?" They don't know where to call. They phone public health.

This is clearly not a preventive step we can take. It's certainly not health promotion. At best, we're preventing someone from dying prematurely. We don't offer an emergency support service of the type the person needs. They're at a crisis that might have been preventable had there been some kind of intervention before that, long before that, and public health is not in a position at this stage to offer that.


There is an agency we work with known as Community Care East York. They have a CIA or client intervention and assistance program. If they know about a case like this, they will go in and assess the person, and if they're not immediately signed on for however many hours of homemaking or the like, they'll continue to go on an outreach basis, just making sure that the person's needs are stable or that they haven't changed their minds about what they might want or accept on a given day. They are supportive, but they don't give up on a person just because they say no in the first instance.

What we are concerned about is that the draft bill under section 20 really assumes that the person is able and willing to pick up the phone and access services. In fact, the section opening on section 20 is, "When a person applies to an approved agency for any of the community services...." "When a person applies" implies that someone is ready and able to pick up the phone and knows what that one number is etc. Often these people literally can't get out of their house, and they may or may not be consenting; they may or may not even be competent. It's very difficult to even get in and assess what their needs are or whether they're in an emergency or just an urgent or chronic situation.

It needs more than one perspective, I would say. Thinking of the preceding presentation, it really needs a multiple approach: at minimum, a nursing and a social work perspective jointly. What we've described in our brief is an outreach team, without trying to prescribe what professionals or others might be included in that; some constellation of people who have a range of skills and perspectives so that any need within that diverse range can be met.

I would also say that there has been some assumption that the solution to some of these community situations will be the Advocacy Act and the Substitute Decisions Act. I'm familiar, from some of my previous discussions when the Muriel Smith case was at its peak, that those acts will not provide a substitute for the kind of service delivery we really need here. The advocacy system will allow rights advice to be given and consent to be confirmed or denied and the Substitute Decisions Act similarly will provide a range of alternatives in the event that the person is incapable of giving consent, but it doesn't substitute for someone knocking on their door to see how they're doing and being able to provide a response when they come to the door and are obviously in a much more precarious state than anyone ever imagined. That kind of service is still needed.

At this point, I'll go to the dental care example that's on page 6. We get a number of calls like this. We've said about four calls per month, but that's absolutely the tip of the tip of the iceberg, I'm sure, because our dental staff don't offer service to seniors and we don't really even publicize it. Somehow people make the mistake of phoning us and we write down how many calls we get, and we get about four a month. If there was any modicum of service we provided, I'm sure the number would skyrocket.

The example given is of a woman who's got multiple medical problems. All of these may be picturable by the committee: excruciating toothache pain for over a week, on top of diabetes, high blood pressure and what medications she might be on for all of those; very little income, going to food banks, and can't afford to get her tooth pulled because, at minimum, with our assistance, it might cost her $50 or $60. And if she goes to a dentist or goes to a hospital, if she feels it's an emergency or some good Samaritan takes her, she'll be presented with a bill for up to $200, and no one will know whether it's at the bottom or the top end of that range until they've actually gone in and provided the service. In other words, there's no free estimate, in terms of our experience, with providing dental services.

We feel that this is really a disgrace, that people who have lived all their lives in this society, in any society, ought to have freedom from pain, at the very least, and not be made to suffer under inhumane conditions. Right now people are suffering because of a lack of even emergency dental care. Forget basic dental care -- not even emergency.

As I've said, there are many other complications that can ensue from poor dental health. There's chronic pain; risk of infection, and that can be either localized or it can generalize to other parts of the body; substance abuse; poor nutritional status; reduced interaction with others; and possibly premature institutionalization. These are not beyond the realm of possibility at all. They happen on a regular basis in terms of what comes to our attention.

I recognize that the staff and the decision-makers in the long-term care consultation process have had to make some very difficult choices as to what's in the basket of services and what's not, so personally I'm not optimistic that you'll turn around on a dime and include basic dental care within the basket. However, we do feel that it needs to be mentioned again and again and presented as an opportunity for someone to do something about. If it took Mayor Prue 20 years of coming to Queen's Park, I'm still young. I can come another 20 myself. I hope it wouldn't take that long.

Perhaps I'll stop there and ask my colleagues if there's any further points to make.

The Vice-Chair: Any other presentations? If not, questions.

Mr Malkowski: Thank you to the presenters, Mike Prue -- mayor -- and Dr Sheela Basrur. I really appreciate the representation from my own community of East York and I think it is important to recognize that we have such a high number of seniors, as well as a high number of disabled people, in the community. I've seen this community being real leaders in this area in terms of having the courage to make very difficult decisions and to develop a very courageous plan to meet the needs of people in the community. I'm very impressed with the leadership that I've seen in terms of pulling key members of the community together. We've seen the East York Health Unit and Community Care East York working together. This is a real model of excellence, I think, and it in fact reflects a real community spirit where we're seeing the interests of consumers in the community really being reflected.

The legislation that we've developed, just in terms of your own experience, we've just begun this development, and yet already we see you as being a model of excellence in terms of being able to pull a community together. In fact, the district health council of Metro Toronto has identified East York as a model of excellence and an area for an MSA.

Maybe you could tell the committee what type of improvements you would identify with the establishment of an MSA in East York. What do you predict in terms of improvements in services compared to the situation as it presently stands, and how do you see an MSA actually changing services and improving them for your community?

Dr Basrur: That's beyond the scope of my prepared deputation, but I'll give it a try. The proposed benefits of the long-term care reform are outlined in the bill and all of the companion documents, and personally I would foresee that the vast majority of those would apply in East York as they're expected to throughout Ontario. If anything, I would see that East York provides more fertile ground for the development of a proper MSA and long-term care system than in other areas because we are small. I think small is pretty great, as opposed to being inefficient. It's very effective. People work together, they know one another, they trust one another and they're willing to come together in the same room on the spur of the moment and work together in a very collaborative way.

I mean, the fact that this booklet was produced by 26 different organizations -- I'm not talking members, I'm talking different governing structures -- they all got together and pooled their resources for the purpose of promoting a common good. That's tremendous, and that was achieved within, what, six months? That speaks a lot to the willingness of our community to work together.

My hesitancy to answer in detail is that I'm not contained within the basket of services and I wouldn't want to comment on how other organizations are going to reorganize their governing structures and their services and make predictions about that. All I can say is that I see a tremendous amount of willingness. I have been involved in a number of the meetings for planning the services, and there's a constellation of local agencies working with the Metro-wide ones and will be, as was mentioned earlier, applying for planning dollars to put a proposal together.


In terms of benefits for the community, I have a feeling that it would be a way of galvanizing community involvement in services for seniors in a more consolidated way. I think there's a lot of volunteer activity and community interest in the specific programs operated by various agencies that are really too numerous to mention. There's a lot of community involvement, but perhaps there can be an even greater outcome if those energies are pooled towards a common goal. I don't see it as creating a bureaucracy; I see it more as harnessing those energies and really making them that much more productive and effective.

Mr Prue: If I can just add, the one thing that's been really unique is that the agencies in East York themselves have taken the initiative. This hasn't come from the health unit or from the political structure; it's come from the agencies themselves. Our community development council, which is our social planning agency, and most of the seniors agencies have come down and they have decided that the MSA is the way to go. We really bow to their expertise. They deal with the people every day and they believe that, by coming together under the umbrella of an MSA within our community, they can better serve those people. So they are supporting it and therefore we are supporting it.

Mr Malkowski: If I can just have one final question, one thing I have heard again and again, especially from some opposition members -- specifically, I think, the Conservatives have said this over and over again -- is that there are some real concerns that the establishment of the MSA is just going to be one huge bureaucracy and the creation of more bureaucracy. Yet what you're saying is the complete opposite, that these in fact are unfounded fears.

Could you just tell us how you see the community responding to an MSA and do you think this is a model that could be used throughout the province, and that we should not be fearing the creation of a new bureaucracy but that you're seeing an agency that would serve the needs of the community and that maybe some of this concern and confusion can be distilled because what you're saying is more solidarity in terms of the various agencies? How does East York feel about this?

Mr Prue: It is difficult to speak for other communities. East York is a large community in terms of Ontario, but it's the smallest community in Metropolitan Toronto. Certainly some of the other communities in the GTA are larger and have different problems.

Our size is unique at 100,000 people. It is unique that we can deliver a kind of service and know the community very well. I don't know whether this will work in every community right off. I would be more than prepared, and I think all of our social service agencies would be prepared -- if you want a community to pilot it, we would be more than willing for you to let us pilot it and see where it's going and how it needs to be improved before you go out to either larger or smaller communities. We think our size and the large numbers of seniors and our history of being able to look after them for so many years makes us an ideal location. I can't speak, and I won't speak, for every community, because I don't know how they'll be affected. I don't know their structures. But certainly our structure lends itself to it and we're looking forward to it.

Dr Basrur: May I also add to that response that as a bureaucrat, I suppose, I have not heard anyone speak in favour of creating a large bureaucracy. Everyone -- if there's one point they're agreed on, it's no one wants a large bureaucracy. So I have a hard time imagining how, against all of those efforts, we'd still wind up with 42 big bureaucracies that nobody wanted. It just doesn't seem plausible to me that all the energy and paper it takes to create a big structure would happen despite everyone's best efforts.

Mr Prue: Welcome to government.

Dr Basrur: I'm young, like I said. Give me 20 years and I'll understand.

The second thing I would say is that, in my own experience, there can be a lot of personal flexibility and choice and control for consumers, which is how the consumers will ultimately view the success of MSAs. That can be achieved depending on the internal organization and corporate style of the governing board and of the management team and the way in which they organize their services. If they choose to see things not in a hierarchical pyramid with someone at the top and a bunch of people at the bottom, then I think it speaks very favourably to an organization that will be able to respond to diversity. It must respond to diversity, and there's absolute agreement that it needs to among all of the service providers. So again, if there's that kind of universal willingness to see that end through to completion, I'm pretty hopeful that it'll get there.

Mr Malkowski: Thank you very much for your presentation. It was certainly full of excellent facts. I know the Ministry of Health has in fact targeted East York as a real model, having seen that agreement reached by the district health council of Metro. So I would like to thank you for the leadership and for sharing this model of solidarity with the community, and I wish you luck in continuing to meet the needs of seniors in East York.

Mr Jim Wilson: I should say to the presenters and to Mr Malkowski, I'll take your word for it that you need an MSA in East York. If I were Mr Malkowski and my medical officer of health and his worship the mayor were so in favour of an MSA, I'd be fighting for them too. It does lead me to a question, though, and perhaps another comment.

You're the only health unit that I'm aware of in the province that isn't actually fighting to become the MSA. That's the debate and wars that are going on in the rest of the province. I know in Simcoe county, for example, they're constantly meeting with me and sending us letters saying, "We better be the MSA because we have all the resources now." So you might turn out to be unique in that area.

I do want to know what the feeling of your employees is, though, at the health unit. You, I assume, are carrying out many of the functions that an MSA would carry out now and there will be displacement of jobs as those people, I assume, would have to go work for the new bureaucracy. Has there been a discussion? You being the chief medical officer of health, an advocate on behalf of the staff, how do your nurses etc feel about this?

Dr Basrur: First of all, with respect to the interest of other public health units in becoming the MSA or at least expanding their mandate to include all long-term care, I think that pertains exclusively to the health units that operate home care programs, and not all do. None of them in Metro do, and outside of Metro there is a small number that do not provide home care. I wouldn't try to name them for the committee, but they do exist. There will be a brief submitted, I believe, on August 24 to committee from those with home care programs, and they really would speak for themselves. Even if -- well, I won't speculate. So that's why we're not getting involved in the governance issue. I think if someone else wants to figure out how to make the new system work, I'll wish them well and we'll work together.

Mr Jim Wilson: That's a very honest response. We're still trying to figure it out here, so --

Dr Basrur: Secondly, with regard to worker displacement --

Mr Jim Wilson: I'm sorry, I must correct myself. I assumed -- I didn't know in Metro that you didn't deliver home care, for example.

Dr Basrur: That's right. There's the Metro Toronto Home Care Program. That's a big bureaucracy.

Mr Jim Wilson: That takes them all, yes.

Dr Basrur: That's a large organization which covers Metro Toronto. Although the Health Protection and Promotion Act outlines home care as one of the public health programs and services, it's not in Metro.

Mr Jim Wilson: Oh, okay. So you likely won't have much of a displacement with staff at all.

Dr Basrur: Displacement per se, no. But as I said at the beginning, there are some functions that our public health nurses do that we would like to turn over to the MSA, and maybe on that note I'll just ask Pat and Janice to say a few words.

Ms Pat Thomas: Just in reference to that is going back again to the whole area of where we get the crisis intervention calls at 3:20 on a Friday afternoon and, "What are you going to do and how are you going to help this individual," it's the individual who is not connected to services, perhaps doesn't wish those services initially, and needs some intervention in order to stabilize their risk situation to an acceptable level, and who is going to do that? We do not clearly see that at the present time outlined in Bill 173. It may in fact be part of case management, is an important role of case management, but from the writing of the bill, it looks like it's when the person is already a part of an MSA or has the ability to outreach themselves. There are many, many clients in our communities who are not able to do that.

Traditionally, public health has been one of those agencies receiving those kinds of phone calls, doing those kinds of assessment and coordination of services.


Ms Janice Leet: I would just like to say that, being a community health nurse, for the last five years since Community Care East York has come into being we have been able to feel very confident at referring seniors and care givers to another agency. Therefore, our primary concern is primary prevention. That's why the community resource awareness committee was formed, because the 26 agencies in East York servicing seniors and disabled adults have identified the main problem for seniors and care givers as how to access services. So we're putting our energies into population base, reaching as many people as we can to assist them in finding the resource, but without necessarily calling us, ie, the pamphlet. But that's where client intervention comes in, and that's where we need it in the MSA.

Getting back to Mr Malkowski's question, what do I feel is the main difference with the MSA, what can the MSA do for seniors and care givers, is just that: prevent the frustrations on the health consultation line that we staff from 8:30 to 4:30. We get so many people calling -- calling from New York City, calling from all over -- very frustrated. We might be the seventh or eighth call. With all our advertising and outreaching, I wonder how it is in other municipalities. I know, just being a consumer, how difficult and frustrating it is to just know who to call. That's the main thing I see the MSA can really --

Mr Jim Wilson: In rural areas like mine, they just referred one to the MPP's office. So give them Mr Malkowski's phone number.

Ms Leet: Now, that's an idea.

Mr Jim Wilson: Just "Jim will do it" is what I hear.

Mrs O'Neill: I just wanted to make two points, if I may. I find this a very helpful booklet, and my own communities have similar booklets. I guess what I'm looking at -- and I guess I want to go back to a comment Dr Basrur made -- I'm confused, though, that an MSA is going to be able to be one phone number when there are at least 100 phone numbers in here. I still don't know whether you can foresee that possibility. I wonder if you see yourselves or see any one of these groups taking the lead in East York, or if you see that East York would have to go in with another geographical area in Metro Toronto, because we're talking about 15; you've got 100,000 people.

We've had two other groups from Metro Toronto in here today who have definitely got concerns and what I would consider some serious misunderstandings about this bill and expressed those today, one being from North York and one being from a part of eastern Toronto. Can you respond to that? Because, really, those of us who have worked on this and worked on Bill 101 still have difficulty feeling confident that we can accomplish in Bill 173 what is being proposed.

Dr Basrur: I'm just speaking in terms of personal opinion, because I don't think there is a right answer to your question. I can't speak in retrospect; I can only predict, which is a little dicey. And I'm not part of the basket, so I'm talking about someone else's bread and butter on top of it.

I think in terms of whether the 101 numbers could all be included under the MSA's roof, you're quite right; absolutely not. It might be that there would be a direct or indirect link between the basket of services and what we've listed in the booklet, but it might not make sense -- it probably wouldn't make sense -- for some of these to be included.

I think the approach we're taking in East York -- I may be proved wrong, but I think this is what feels right to me -- is that we're working with the things that clearly are within the basket as our starting point. So the Meals on Wheels programs, the home support, the home care and visiting nurses and so on are clearly going to be within the basket and we're not worried about what's out on the margins at this point.

We're trying to sort out what the core of service will be, how it'll operate, how people will be assessed, how they'll flow through the system etc. How will the meals program operate if it's part of a larger umbrella? How would the transportation service operate? How does it operate now? How would it operate in the future? What's the give and take in making the transition? That type of thing, and doing it on a programmatic basis, doing it at a governance level. I am speaking into the future on some of this, because we're really still in the starting phases.

When it comes to the more peripheral areas; public health, for example, is part of a second tier of linked services. We're definitely not going to be in on the nitty gritty of planning and incorporation and so forth, but we will be involved in the planning. We sit at the planning table as members but when there are decisions that need to be made, they're more germane to a core group of people.

It might be that some of the agencies that are listed in here like -- I don't know. Maybe there's a suicide prevention service of some kind. Those I think we might have to call on a case-by-case basis. I wouldn't want to predict which way any one of them would go, but likely we'll err on the side of certainty in terms of what ought to be in.

Mrs O'Neill: Thank you for trying to be helpful. The other is the dental problem of seniors. You may be interested to know that we're going to Hamilton on Thursday and the Ontario Dental Hygienists' Association is going to present in, I think, more detail than yourselves. This is a problem that's been brought to me. I happen to be the critic for seniors of the Liberal Party and it's been brought to my attention by several dentists and certainly by the organization of the dentists in Ontario.

I really didn't realize it was quite as difficult as you mention. If a doctor refers the case, can it be covered by OHIP? Is that the difference between the emergency -- is it possible to get a hospital extraction, I guess is what I'm saying, in any case?

Dr Basrur: The information I obtained was from our dental hygienist and what she advised was that it's not possible. That doesn't preclude that a hospital might have its own unique arrangements or certain providers have worked out something. There are always going to be exceptions. But in our area, the experience has been as we've described it.

I would say that I really -- I must speak only for East York. If you go to the city of Toronto, they have dental clinics funded 100% with local municipal dollars through their health department. We don't have that provision so we don't have anything. But there might be variations across the province that are similar.

Mrs O'Neill: So some of it is through the social assistance provisions of -- certain cities have used this as an optional program in some cases.

Dr Basrur: Yeah. For example, in Metro if you're on general welfare assistance, you have emergency dental care. But I believe that entitlement ends at age 65.

Mrs O'Neill: I see. Okay, I think this is something that is really important and I hope it will be included in the bill. You and others, I'm sure, are going to emphasis that, and it certainly is health care.

I think it's most important that you talk about how the complications then arise and also I think there have been mistaken identities by seniors in themselves that they're suffering from a dental problem and it's not a dental problem at all; it's something more serious.

Dr Basrur: Right.

The Vice-Chair: That completes the hearings of the committee for this evening, I understand. The Ontario Dental Hygienists' Association had a presentation handed out to you and I'm reminding you to take it to Hamilton with you. I don't know what will happen if you don't but that's the request. You may have to go without -- without the presentation, I mean.

Thank you for your attendance. The committee is adjourned until 10 am tomorrow morning in the same location, with a new Chair.

The committee adjourned at 2149.