Thursday 25 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

Reg Heasman

Perth County Long-term Care Planning Committee

Sandra Hanmer, chair

The Lambton Alliance

Joyce Anderson, chair

Jim Larocque, chair, Lambton Senior's Association

Do-R-Best Women's Institute

Mona May Thompson, program coordinator

Helen Havlik, member

Port Franks Seniors Action Club

Ken Reffell, member

Kathy Desai

Anne Fowler

Victorian Order of Nurses, Southwest region

Janice McCallum, president, Middlesex-Elgin branch

Kathy Bamford, executive director, Oxford branch

Catherine Goetz-Perry, executive director, Grey-Bruce branch

Belle River and District Community Council

Janet St Pierre, executive director

Cheshire Homes of London Inc

Mary-Anne Elie, board member

Judi Fisher, executive director

Participation House Support Services, London and area

Elizabeth Leighton, board president

City of Windsor social services department

Dana Howe, commissioner of social services

Mrs Peggy Davis, director, special services

Independent Living Centre, London and area

Steve Balcom, president

Ontario Community Support Association, areas 1, 2 and 3

Sue Hillis, director, area 2

Heather Richardson, director, area 3

Middlesex-London Health Unit

Dr Graham Pollett, medical officer of health

Kent County District Health Council

Bruce McCallum, chair, long-term care steering committee

Mary Lee, member

Paul Balkwill, chair, multiservice agency committee and member, long-term care steering committee

Persons United for Self-Help, southwestern region

Myrtle Evans, vice-chair

St Joseph's Health Centre, Sarnia; St Joseph's Health Centre, London

Don McDermott, administrator, Sarnia centre

Philip Hassen, president, London centre

District Health Councils of Southwestern Ontario; Thames Valley District Health Council

Kathryn Bamford, chair, Thames Valley DHC

Judi Fisher, member, long-term care planning committee, Thames Valley DHC

Paul Huras, executive director, Thames Valley DHC

Lynne Hammond; Doris Adams; Susan Deffett; Donna Jordan

Canadian Red Cross Society

Mary Kay Croft, regional director, southwestern Ontario homemaker service

Walter Willms, council president, Windsor branch

Persons United for Self-Help, Windsor and Essex county

Joan Cowie, president


*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

Substitutions present / Membres remplaçants présents:

Abel, Donald (Wentworth North/-Nord ND) for Mr O`Connor

Caplan, Elinor (Oriole L) for Mr McGuinty

Haslam, Karen (Perth ND) for Ms Carter

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

Sutherland, Kimble (Oxford ND) for Mr Rizzo

Wessenger, Paul (Simcoe Centre ND) for Mr Owens

Winninger, David (London South/-Sud ND) for Mr Martin

Also taking part / Autres participants et participantes:

Ministry of Health:

Czukar, Gail, legal counsel

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

Wessenger, Paul, parliamentary assistant to the minister

Clerk / Greffier: Arnott, Doug

Staff / Personnel: Boucher, Joanne, research officer, Legislative Research Service

The committee met at 0856 in the London Convention Centre, London.


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. I'd like to call the standing committee on social development to order. We begin our Thursday, August 25, session here at the London Convention Centre.


The Chair: Mr Reg Heasman, is our first witness this morning. Welcome to the committee. We have a copy of your presentation, so please go ahead once you're settled.

Mr Reg Heasman: Thank you, sir, and thank you to the committee. I assume that you rearranged your schedule so that you could encompass far more people here in London. I thank you for that. I also want to add thanks to Mr Arnott, the clerk. I'm sure he doesn't get as much credit as he should get for the good work that he does.

The Chair: On behalf of the committee, I accept that for Mr Arnott. We know all the work that he and his staff do, so we're glad you noted that.

Mr Heasman: The agenda leaves me as just Reg Heasman. I'm afraid I am very much that. I do not come here representing anybody other than my own views. I do not have a constituency that I speak for.

As the front page of my brief will tell you, I am a retired federal public servant. Since I retired in 1988, I suppose I have devoted a very large amount of my time to volunteer work. In fact, I might almost refer to myself as being a professional volunteer. With that in mind I have chosen as the subject to talk about and to address you on that of volunteers and the multiservice agency.

The organizations which I am involved with: I'm a board member of the United Way of Sarnia-Lambton; I am a board member of the Strangway Centre for Older Adults, which is an adult centre in Sarnia; I'm a member of a group called the Senior's VIP Service, the volunteers in public service; I'm on the board of a group called the Lambton Seniors' Association; and I'm also a member of a group called the Lambton Alliance, which is a pretty hot ginger group, which has as its mandate to ensure that the point of view of consumers is well covered in your deliberations.

Last year, I took part, with a group, in organizing and producing a series on volunteers on our local TV program. This series covered a complete spectrum of volunteer activities. The thing which was driven home to me very, very clearly indeed was the enormous diversity of activities that volunteers contribute to and the extent of the dedication of volunteers in what they do.

It became very clear indeed to me, and I am fully convinced of it, that the contributions that volunteers make forms the backbone of our social infrastructure. I think our society would collapse if we did not have the help of volunteers. What this represents is part of our culture, that we have a concern for our fellow human beings, and it's a key indicator of the wellbeing, of the health of our culture.

Volunteers also play a very, very large part in our health care. It's on the relevance of this that I am concerned today. I want to talk about volunteers in relation to this remarkable piece of legislation that we have before us.

The first point I want to make to you about this bill is that I sincerely believe it is wrongly named. It's called the Long-Term Care Act. It isn't in the least bit about long-term care. It's about long-term care services. I think, from what I saw of you on television, the number of people who came to talk to you were mainly people who had interest in the services which you people -- you, the government -- fund for long-term care.

I would suggest to you that it would be much more appropriate and it will drive home the point much more clearly if this act were renamed, and there is a clause in the act, somewhere near the end, and I would suggest that one of the things the committee should seriously think about is changing the name of the bill to that of long-term care services or even long-term care service funding, which is really what it's about.

In reality, long-term care is largely outside this government system. There is far more long-term care which is given within the community which has nothing at all to do with the services that you people fund. It's the care of the elderly spouses of one for another; it's the love that the parents of a handicapped child have in caring for him or her; it's the care which is provided by family, by neighbours and by friends. That represents the bulk of the long-term care. That's the care which is ongoing and going on all the time.

The next level is that of the contribution that volunteers make, their dedicated efforts through their organizations. The contribution that this long-term care service legislation which you have before you is mainly concerned with that part of long-term care for which you provide the funding for purchasing the services.

An example of this came home very clearly to me at a time when I was involved with our local Alzheimer society. The district health council had a study done in which it tried to get a measure of the prevalence of Alzheimer disease in our community. The consultant report that came out came to the conclusion that there were probably around 500 cases of Alzheimer in the Lambton county region. Yet, by a completely independent approach to that determination, a determination which I think is fairly reliable, with some mathematical validity behind it, the thinking came out that there were probably between 1,500 and 1,700 cases of Alzheimer disease in Lambton county. Of course, the difference between those two numbers is really a measure of the amount of people with this debility, with this condition, who are being cared for outside of the system.

I'd like to move on now to more about the volunteer piece. Over time, within the systems that you people are concerned with, volunteers have built up a range of services that are integral to that system. Things like Meals on Wheels are very largely dependent upon the contribution that volunteers make. Sometimes these services are partially funded by government. They are operationally dependent, however, upon the dedication of volunteers. Funds provided by government go more towards the hiring costs of full-time staff and administration, but they seldom, seldom go to those who supply the time and labour to make the services a success.

In the legislation, Bill 173, the services which the MSA is going to provide, as listed in subsection 2(4) and described as "community support services," are almost entirely offered by volunteer groups. A few may be provided through funded government programs, but not many. Most of those listed in subsection 2(5) are provided by home care, but not all. Friends and neighbours also do a lot of these, as with those in subsection 2(6). It's only those in 2(7) that are offered predominantly by professional service providers. But the government intends that all these services will be provided through the multiservice agency, as expressed in subsection 12(1). It isn't stated, but it's implied that the government expects that volunteers will continue to provide these services. I would ask you, is this a reasonable assumption?

It's estimated, for example, that there are 75,000 active volunteers involved in providing those services which come under the long-term care system. It's difficult to get a measure of the amount of time that volunteers contribute, but the value of their service must surely amount to millions of dollars. The loss of even a portion of this will be felt both by the MSA as well as by the clients in need.

What are the special features provided by volunteers? I would suggest to you that they are generosity of time; enthusiasm for the endeavour they're involved in; they are truly, to use a very bureaucratic expression, results-oriented; and the final thing about volunteers is that they're extremely intolerant of administrative practices. This came very clearly home to me when I discovered the number of volunteer charitable organizations that annually lose their "charitable" status. Volunteer organizations do not do very well in meeting the requirements of Revenue Canada for retaining their "charitable" status and they frequently get into serious trouble in losing their "charitable" status.

While the government can provide funding to purchase care, the volunteers bring something very special to their contribution: They bring caring. They do more than provide care; they provide that care in a caring fashion. I'm not saying that this does not come through the service providers. I think it does, but the one feature, the one characteristic of all people who are involved in volunteer work is that they do come from that foundation of being caring.

What is the motivation of volunteers? Volunteers who freely give their time are motivated by factors which cannot easily be defined. They certainly involve a commitment to the organization to which they belong, but this is a fragile relationship which can easily be severed. When the commitment is related to the independence of volunteers, and this is one of the very strong features about them, the strength of the tie can be seen as tenuous. Volunteers expect to get some personal satisfaction from their association with their organization. They must feel that they belong, that their services are valued, that they can see tangible results of their efforts. Will the restructuring and the transfer to the MSA have an adverse effect on this relationship? Will volunteers be able to build up an allegiance, as they have done with their own organizations, to the MSA?

Managing a volunteer group is much more difficult and complex than running a small enterprise. In the management spectrum of volunteer groups, there's no place for control. Direction and instruction are secondary to the independence and therefore the personal wishes of volunteers, and that's always the critical factor in managing a group of volunteers. The wrong suggestion can very quickly disenchant a volunteer. A volunteer group is a most sensitive organization. Emotions can, at times, run high. Is this the sort of arrangement suitable for an MSA?


Finally, funding, and this subject, I'm sure, will be addressed much better by organizations like the United Way, but many volunteer groups are funded either through citizenship, through Comsoc or through the United Way. Currently, in our community the United Way supports a number of volunteer groups. The question has already been posed whether the funding provided by the United Way will follow the volunteer group to the MSA or whether the contributors to the United Way will raise an objection to the use of their funds going to the government agency. Time will tell.

By going through the allocation of funds from our United Way, about $500,000 on an annual basis goes to funding volunteer groups. If Bill 173 is followed through and comes into form the way it now exists, the United Way will have to make a decision of whether that money is going to go to the MSA or whether it will be reallocated into other areas.

It is my suggestion that volunteer groups remain outside the MSA and continue to retain their independent identity. I think to some extent, if it is the intention of the minister, it is pretty outrageous to presume that volunteer groups will readily move over to form part of that organization. There will still be an enormous drive to make that contribution to society, but it will be the way in which it's made.

I don't really think, from the documents I've seen that have come out of the government or in this bill, that the government really understands the complexity and sensitivity of what it intends to take over with these volunteer groups. I think it's at risk of destroying something. I would suggest to you that it would be advisable to leave the volunteer segment out of Bill 173. Thank you very much.

The Chair: Thank you very much, and we'll go to questions with Mr Wilson.

Mr Jim Wilson (Simcoe West): Thank you, Mr Heasman, for what I think is an excellent brief on behalf of volunteers. I just want to make a couple of points that parallel yours. I would certainly agree that volunteers are intolerant, to a certain degree, of administrative practices. You mentioned the forgetfulness at times to adhere to Revenue Canada regulations, and I'll tell you, from the provincial side, we regularly have to reincorporate volunteer agencies under provincial statute through private bills. So it's a frequent occurrence at Queen's Park, and 99% of the time it's simply exactly that. Somebody either wasn't aware of the requirement or had other things to do and wasn't about to spend time filling out the forms.

I think you're right in your final remarks when you talked about the government perhaps not understanding the complexity and sensitivity of volunteers and volunteerism. We've heard from government members in this committee, when this topic has come up, that the government does understand and the proof in the pudding is that the government gives out awards every year to volunteers, you know, that there are a number of provincial awards and ceremonies that take place. But, just to remind the government, those people didn't volunteer for the government. They volunteer first for some organization or agency in their local community and the government comes along after that fact and gives them a nice award. Many of them, all of them I think would continue to volunteer, whether or not the government gave them recognition.

Your most important recommendation is to keep volunteers outside of the MSA structure. My opinion would be, as this bill is currently drafted, that would be impossible. Remember, there's pressure on the government from unions that volunteers actually take unionized jobs, and in essence, a lot of this bill is simply a unionization drive; it's to throw all service providers under one umbrella and unionize them. I agree with your contention that it's not really about services, and we intend to vote against the legislation. Do you think, in your reading of this legislation, that it's salvageable to meet your objective of keeping volunteers out?

Mr Heasman: Yes, I think Bill 173 is salvageable. There's no question of it. I think there are parts of Bill 173 which are excellent. It is a very remarkable piece of legislation. I think it probably will be seen in hindsight, if it can be brought to that, as a masterpiece of legislation, but certainly I think there has got to be far more consideration given to many of these factors. I don't accept that point about the volunteers and the unions. There is plenty of room for everybody. You just talk to any volunteer groups and you'll find that there's still room for more volunteers. There's plenty of room for volunteer work. There's nowhere near enough of it and it's particularly in that area of the caring matters where real sensitivity, where empathy, where kindliness is important.

The unions, rightly, are concerned with jobs, of people having tasks to do and for which they are paid, and reasonably well paid. I could expand tremendously on some of the things I think I would like to see put into 173. I'd like to see mandated benefits for those dedicated people who do home support work. I think many of those people who are single mothers, who are mothers on welfare who go out and do that tremendously important work in helping the elderly, the frail and the handicapped in-home, I think it would be a tremendous thing if Bill 173 put in mandated benefits for those people.

There is a government program which I would commend to your attention. You probably know about it, the program called Good Neighbours which is funded by Citizenship. That's a piece of legislation which I think again is remarkable in that it's encouraging people, it's encouraging a behaviour of change and I think somewhere in here on 173 and long-term care services we need something like that. I've given you a lecture, I'm sorry.

The Chair: Thank you very much for that, but thank you in particular for talking so forcefully about the role of volunteers, and we thank you for coming from Sarnia.


The Chair: I call the Perth County Long-Term Care Planning Committee; Sandra Hanmer. Welcome to the committee.

Ms Sandra Hanmer: Thank you very much for the opportunity to speak before you this morning. I'm very pleased to be here on behalf of the Perth County Long-Term Care Planning Committee to address our issues and concerns regarding Bill 173. I also am aware that the committee has convened earlier than originally scheduled this morning in order to hear additional presentations, including ours.

Just to give you a little bit of background, the Perth County Long-Term Care Planning Committee was established in November 1993. Our responsibilities include identifying and analyzing the needs related to seniors and people with physical disabilities in Perth county, establishing key planning priorities, developing a multi-year, county-wide plan to address strategic planning and service needs and to prepare a local implementation strategy for long-term care.

The implementation strategy will look at such things as service expansion and enhancements, the equitable distribution of resources and how a multiservice agency or multiservice agencies will evolve in Perth county.

Attached to the brief I've given you this morning is a list of the membership of the Perth County Long-Term Care Planning Committee. Also in way of background, the Huron-Perth District Health Council was established in June 1994. As I mentioned earlier, our planning committee was put in place prior to the establishment of the district health council in order that long-term care planning could proceed without delay. We have been resourced directly by the Ontario Ministry of Health through this process, in the absence of the district health council, by the London area office. Now that the district health council has been established, a member of the council has been appointed to our committee as a liaison.

Extensive long-term care planning in Perth county has been taking place for the past two and a half years. Five local long-term care planning committees exist in the natural communities throughout Perth county. These local long-term care planning committees all have representation on the county-wide committee. When our committee was pulled together in the fall of 1993, we were given a very strong message from the community. We were told that in planning for long-term care services, it is fundamentally important to build on the strengths that already exist in our county, and also that our planning process must be open and participatory.

Ideas we'd like to carry forward in terms of our discussion of Bill 173: People who do not actually sit on the long-term care planning committee must have easy access to it and must feel that they have a voice and are influential. We were very fortunate to have an opportunity on May 31 to present to Karen Goldenberg our recommendations and issues regarding MSAs. I have included this information to you with our briefing.

A great deal of support exists in Perth county for the long-term care reform objectives outlined in the legislation and in the compendium. The concepts of easier access, consumer centred, less assessment and services that are well organized and well coordinated are well received by both our planning groups and communities.

Concern has been expressed, however, with regard to the impact the multiservice agency may have on voluntarism. Many services to seniors and persons with physical disabilities are delivered by volunteers. Our volunteer base has been established over many years. People in small communities want to be able to support one another. We are concerned that the establishment of the MSA may mean the end of community-based agencies and volunteers.


We think it is important to foster the concept of a multiservice network as opposed to a multiservice agency. The term "multiservice agency" conjures up an image of one single, very powerful central body as opposed to something that is grass roots, local, community owned and operated, flexible and movable. It is for these reasons that strong support remains in Perth county for an integrated model including a brokerage concept. While different models for service delivery may work in different parts of Ontario, it is our general impression that the limit of 20% purchase of service may be too small and could have a damaging effect on the future of service delivery in Perth county. In reviewing the legislation, we are unclear as to the process for the appointment of board members for the MSAs. Will they be appointed by the minister? Will they be appointed by a provincial order in council? We strongly feel that the mechanism for the appointment of board members needs to include local input, as provincial appointment of board members would not foster local ownership and local accountability.

On the issue of accountability, who is the MSA accountable to? Is it accountable to the district health council? Is it accountable to the Minister of Health? What is the relationship between the MSA and the local district health councils? What is the relationship with the ministry? This all must be very clearly defined.

In addition to its planning responsibilities, this legislation also appears to be giving fiscal responsibility to district health councils. If this is the case, is the infrastructure required in place to ensure success? Are district health councils going to be, and do they want to be, money managers as well as planning bodies?

Perhaps some of the questions I have raised will be answered in the regulations that will follow the act. It would be very helpful if we would have an opportunity to review both the act and the regulations so that we could not only review policy but also the procedure and practice to be put in place. The appeals process appears to be somewhat cumbersome and time consuming. It's important that a local appeal process be clarified. How will the Health Services Appeal Board function? While the appeal process appears to be comprehensive, it must be expedient and efficient.

In closing, I would like to say on behalf of the Perth County Long-Term Care Planning Committee that it's unfortunate we had little time to prepare for the presentation. We feel with more lead time we would have been able to provide a more comprehensive briefing.

The next four years are going to be very challenging as we work towards fully evolved multiservice agencies. We fully support the flexibility demonstrated in supporting the concept of transitional models. We are still concerned with the final vision contained in the document. It's difficult to know what the service network is going to look like four years from now or as we enter a new century. We feel the single model of a fully evolved MSA as captured in this legislation may not be the best option or the only option for all areas of the province.

We still see a great deal of merit in piloting MSA models throughout the province. If this were ever to become an option, Perth county would indeed be most interested in participating. Our planning committee likes to look at issues in terms of what we like, what concerns us about the issues and, given the opportunity, how we would fix what concerns us. Bill 173 is a good start towards integrating long-term care services, and I hope my presentation has given you some ideas which will make it even better. I'd be very pleased to answer any questions. Again, thank you for the opportunity.

The Chair: Thank you very much for the submission and also for the various attachments that you've included.

Mrs Karen Haslam (Perth): I know a lot about Perth county for some reason, and I know how hard they've worked. I think they need to be commended for the type of planning they've done even before the district health council was put in place. I think that shows the importance of the volunteerism and the type of people we have in the county that they do that kind of work. I keep touting Perth county as a very good model when we talk about our natural areas and natural patterns in Perth county and how that's come together and the type of care they want.

In think it's important, though, to hear about two things: number one, rural issues. This is an opportunity for you to explain how difficult offering some of these things can be in rural communities. Because we're looking at two counties now being together in a district health council, Perth and Huron, and they're both very rural ridings. I notice that you're working towards maybe an MSA network and maybe you could talk a little bit about what that would include and how that helps in rural areas.

If you get a chance, you could throw in an idea about how we could keep volunteers involved in the MSA. Maybe you have a suggestion about coordinating or what might work. I know the type of volunteers we have, I know the kind of people we have in Perth county and I know they will be volunteering because that's the kind they are. How can we help them in the MSA?

Ms Hanmer: Mrs Haslam has asked very many questions. I'll try and answer --

Mrs Haslam: Listen, when you're only offered one, you get them all in there.

Ms Hanmer: You get them all in. I'll do my best to answer them. Perth and Huron counties are indeed very rural counties. In terms of planning service deliveries, we've had to look at different models of how we can reach out to all aspects of the county. A single MSA housed in a large centre -- with Stratford being probably the biggest city in the two counties -- will not work from a service delivery standpoint for us. There are very different needs between the city population, and even the five local planning areas I've spoken of are different in size and different in composition. We need to make sure that whatever model we put in place will allow the services to be delivered to the local people who are going to be using those. In some cases, it may even mean going out to small hamlets and delivering service in that aspect.

So the long-term care planning committee is looking at various models. Different things, such as one umbrella MSA comes in mind, with a number of delivery sites, maybe four or five delivery sites. We have a good, strong brokerage model working in place now for service delivery and we'd like to be able to build on that. Services need to be able to move out.

In terms of volunteers, we have a very strong volunteer base and our concern with the volunteers being swallowed up by the MSA, we'll lose some people who are dedicated to perhaps the Lung Association or through other things that are sponsored by the United Way. If there is a mechanism that people can still feel an affiliation to their particular group but yet provide overall service to the county, I think we'll go a long way to be delivering that. And whether it's through the establishment of one volunteer coordinator, similar training, similar orientation, a volunteer bureau where people are registered in one spot, but their own views and their own areas that they'd like to be participating in are kept in mind.

I think there's lots that we can work together but I think it's important that the committee take a look at the different geographical areas throughout the province, and models need to reflect that. The Metro model isn't going to work in a rural community. I hope that addresses some of your concerns.

Mrs Haslam: It does, and I think it shows very clearly why we're on the front of what we do in Perth county, because we've very good people there. Thanks.

The Chair: Thank you very much for coming before the committee this morning, we appreciate it.



The Chair: Our next witness is from the Lambton Alliance. Welcome to the committee.

Mrs Joyce Anderson: I'm very pleased to be here this morning. We're from the Lambton Alliance. With me I have Jim Larocque. He is the chairman of the Lambton Senior's Association which is closely affiliated with the Lambton Alliance. I am Joyce Anderson. I'm a farmer from near Brigden and I've been involved with the alliance since its inception two years ago. I'm the chair of the alliance. I come to the alliance from the women's institute. The alliance represents 60 seniors' organizations in Lambton county as well as women's institutes, superannuated teachers, and retirees from Dow and Polysar.

The alliance was formed in order to study the long-term care reform redirection two years ago, and at that time we held dialogue groups throughout our county. We made a report and recommendations at that time on what we felt needed to be done in the long-term care system. We just happen to have brought a copy of those along today. If you're wanting that later on in the question period, we have it available with us.

We're really pleased to appear on behalf of Lambton people as consumers and we've been following the dialogue groups that have been held locally in our county. We have some overheads to assist you in understanding our presentation and Jim Larocque will man the overhead.

In our consultations two years ago, we found there were several things that had turned up in Bill 173 and we're very pleased to see that there are areas of agreement. We're very much in favour of the single point access.

We'll start on accentuating the positive. Okay. We really like the idea of the single access point. We feel it's really important that we be able to get information, referral and evaluation as well as assessment at that local point under the MSA. We think that's a really good idea, but we're quite concerned about all the other services having been lumped in there as well, which will make it a very large, unwieldy organization and you'll be buying and selling from yourself and it'll eliminate the competition idea. We're very much in keeping seniors in our home. That's something we've found from surveys in Lambton county, that seniors do want to be in their home, but we want quality life in our home and we want it to be cost-effective. If it's more expensive to stay in your home than an institution -- we're very practical. We feel it should be the cheapest method approach rather than staying in the home at all costs, and a quality life is an essential if we're going to be left in our home.

Elimination of duplication: We know there are things in the system where there's duplication but we do believe that some duplication is necessary in order to have competition. If you haven't got more than one point to access different things, then competition is eliminated and there's no way of setting a market price. When there's competition, you tend to get better service because people know there's somewhere else they can go. The other thing with consumers, if you're frail, you don't want to have a hassle if you don't like the service. It's much easier to cancel service at one provider and change to another than it is to hassle and try and straighten it out where you are. We picture in this MSA, the one-stop shop where everything's provided, there really wouldn't be another alternative if you were unhappy with your service.

Turning to our concerns, we feel that the MSA services will create a large, monolithic bureaucracy. We love that big word. We picture that from the legislation -- it says 80% provided by this bureaucracy, and from the list of services, it takes you two pages to list all those mandatory services that it says are going to be done. When it's doing this, it's going to require a lot of administrative staff to administer all those services and to organize all those workers. Currently in our county there are over 20 agencies providing those particular services and they've developed on an as-needed basis, so the people in them are very involved and include volunteers. Some of them are union people, some of them are non-union workers, and if these are all lumped together under one place, who's going to coordinate how to manage this labour mess of the people who have been receiving different rates of return and volunteering? It's going to end up appearing to us that the government's going to have to pay all of them, and probably at the price of the person who's being paid the most now. They're not going to go and make them all volunteers.

There are very diverse services and a large staff. That means it needs a large administrative staff, and in very large organizations, you get a distancing of the workers from the administration and from the general purpose. So you get alienation and you get workers who aren't getting full communications like you do in our current smaller agencies' operation. You lose the team spirit. It can always be lost that way in any very large organization.

Elimination of private agencies: We're very concerned with putting a number on that capping. We feel that the most cost-effective, most efficient service should be the criterion rather than putting actual numbers in the legislation. With the private agencies, there's still consumer choice. Not-for-profit is not always the cheaper alternative.

In our brief on page 9, item 3.5, you'll notice we gave an example about foot care. In our particular county we found that this was quite a startling piece of information that foot care -- the last paragraph right in the middle of the page -- cost $9.70 from the private provider, whereas it cost $37.50 from the other provider, that is, the not-for-profit. Of course, we know the private provider is also getting a profit, so just to say that we want to put all our money into health care and make it not-for-profit so that we're going to be getting the most bang for our buck doesn't always prove out to be that way.

The loss of consumer choice: The consumers are going to be responded to by having competition there. If you're the only one providing the service, it's very easy to sit back and not jump to it and provide what this consumer actually wants. We feel that consumers need to be able to have an alternative so that if they don't like the service, there's someone else.

Loss of volunteers: All of the agencies in our county providing service now depend on volunteers, and we can't see these volunteers volunteering for a government organization. They're affiliated with the VON or Red Cross or cancer or Alzheimer's because of a family member, or there's something in them that clicks that makes them want to help with that particular service. If it's all lumped together in one big agency, we can't see it being able to draw the volunteers or keep the volunteers. Some of them are very tired and they're going to welcome a chance to say "I quit." If the government has to replace all that volunteer labour, it's going to be very costly.

The charitable funding: Also, many of those agencies depend on charitable dollars. Many of them operate on funds that come from organizations that just raise funds, such as the United Way, and we can't picture the United Way being able to raise the kinds of funds it does now if it was to donate it to the government.

The only mandatory services that we feel should be provided by this MSA is the one-stop access for information, assessment, referral and evaluation. It should eliminate the duplication in the agencies through improved communication links and through improved assessment tools. In this day and age there are computer hookups and the information network. All the fancy information highway stuff is available that could be interrelated between the current agencies to improve the communication, without having to eliminate all of them.

Don't put a cap on the for-profit sector. Allow existing suppliers to continue to supply under their own names, and that way we'll be able to keep their management and their volunteers and their resources. The big MSA as inferred in this document will have difficulties with blending the labour force. There will be loss of morale; it will create uncertainty. People even now are worrying about job loss: "Are we working for the right agency?" We fear that there's going to be a loss of volunteers and definitely a loss of charitable giving.

In choosing which agency provides services for clients, we believe it should be judged strictly on qualification of the staff, the total cost and the quality of service.

Thank you very much for listening to our presentation.


The Chair: Thank you very much, and we'll do the questioning with Ms Caplan.

Mrs Elinor Caplan (Oriole): Thank you for an excellent presentation. I have a fairly long history with the beginnings of long-term care reform, and the desires of all of us who've been involved I believe are to see that people get the care they need when they need it, in the community wherever possible, to allow them to stay in their homes and to be independent. So this piece of legislation is supposed to begin the development of that kind of system.

I have some concerns about it because the points that you've made as to the type of model that you'd like to see remind me very much of the original plans for what was then going to be called a single-access organization as opposed to an MSA. The original view was that there would not be overall service delivery by one organization but more of a brokerage model.

The question that I have for you is -- and you've obviously thought about this legislation quite a lot. You've identified some areas where you think this legislation, if amended, could be fixed, and I'm wondering if you could just itemize and identify for us the specific areas you've mentioned, such as the removal of the 20%. Do you think perhaps instead, if there was a principle added to the legislation that required, upon evaluation, that as part of the brokerage model there be a test of who can provide the best and highest quality service at the best price, that might lead to the kind of competition or balance? Is it possible to include that in the legislation?

Second, what are the other areas specifically that you think could be amended to reflect your view that the MSA should be for the purpose of assessment, referral and in some cases perhaps information sharing and case management? I know it's a big question, but I'm looking for points.

Mrs Anderson: Okay, in reference to the 80-20, and you mentioned about the brokerage model, we've learned that we're misspeaking when we think in terms of brokerage model. The buzzwords in the Ministry of Health are that a brokerage model means that you call a point of access and they give you a list of phone numbers and, "Go to it, fella." That's not what we mean as brokerage, but commonly a lot of us think that term means that.

So what we're asking for is a purchase-of-services model. In that case, like you say, we believe it's really important that we have what's the most cost-efficient and effective. We want quality service at the most reasonable cost.

Mrs Caplan: I appreciate you defining the difference between a purchase-of-service model and a brokerage model because I think sometimes the words are used interchangeably. The protection that a purchase-of-service model would give to the consumer would not only be choice but it would safeguard the role of volunteers. In your opinion, is that where the strength of that would come in?

Mrs Anderson: Yes, we feel that's a great strength because it would allow the agencies to retain their present structure pretty much. If they're already providing the service on a volunteer basis or volunteer combination, then that could stay in place, but if it's all put under the one structure, I can't picture someone who's volunteering being quite happy to work alongside a union person doing the same thing, because right now many of these agencies use volunteer coordinators.

But when you get into something larger, you're going to have to have a paid volunteer coordinator. And it's going to make it harder to access those volunteers, because these smaller groups have their ears into the smaller community and the community as a whole in order to attract volunteers to their subject area.

Mrs Caplan: I want to thank you for an excellent presentation.

The Chair: Thank you, again, very much for coming before the committee this morning.


The Chair: If I could then call upon the representatives from the Lambton women's institute. We welcome you all to the committee this morning.

Mrs Mona May Thompson: Good morning, ladies and gentlemen. I'm Mona May Thompson. I'm the program coordinator for the Do-R-Best Women's Institute, which is located in south Lambton in the community between Brigden and Oil Springs, if that helps to locate us any better.

Our organization is 61 years old, and in that time period we have been involved in matters that would improve education, agriculture, health and environmental issues and we have helped to promote women in growth and in their individual development. Our membership ranges from age 24 to 90, so we're very diversified in our ideas. Some of our members live outside our community now in Petrolia and Sarnia as well.

Also present today we have our secretary Mary Louise Piggott on the end here, and present also in the audience is our president-elect for the Federated Women's Institutes of Ontario, Margaret Harris.

The Do-R-Best institute became involved with the district health council two years ago when the dialogue groups were held around Lambton county concerning the long-term care redirection. Members of our organization at that time were part of the facilitating people.

To present our brief today I have Mrs Helen Havlik. She is the past director of nursing at Charlotte Eleanor Englehart Hospital in Petrolia. She is also at the present time chairperson of the Lambton County Association for the Mentally Handicapped and she is on the executive of the Lambton Alliance. She comes highly qualified to do our presentation on the district health council's relationship to the process. I'd like to present Mrs Helen Havlik.

Mrs Helen Havlik: Good morning and thank you very much. I am pleased to be here as well. We are in favour of the legislation in terms of its general direction and its overall purpose. However, we would like to point out that perhaps at this time it would be appropriate for the Ministry of Health and the government to look at district health councils, how they are structured, how they're mandated, what their purpose is, how they flow information back and forth between themselves, their community and the government. Therefore, we would look at them.

In the legislation you have stated -- you have put district health councils there but sort of, it seems to us, as just an afterthought perhaps, just a couple of paragraphs with respect to them. We would suggest that this would be an opportune time to actually put them in the legislation, which I think you have done, but also to state there what their purpose is, how they will function and how they will represent the communities they operate in.

We believe that up until the present time, although we understand there are some task forces in place and we've read some of the briefs on that, there is a change in the purpose and the methodology that they're to use. We think the legislation should reflect that. We think the legislation should have their purpose stated in the legislation and not just be perhaps a direction that's given to them from the Minister of Health. But it should be in the legislation, the purpose of the district health councils.

We understand that their membership is reflective of or should be reflective of their communities. However, I think that it doesn't state anywhere that they are responsible to those communities or that they should represent the views of those diverse groups that they represent on their councils.

So we would ask that some points in the legislation be altered to reflect those ideas: the purpose, the mandate, the structure and how they communicate with the people they serve.


I think that this would serve the government well too, be a channel for people in the government to understand where the communities are coming from, and then certain things would not be imposed sort of from on high. The Toronto model would not necessarily fit the Lambton model, and that sort of thing.

We found, after all of our talking and so forth, and as some of the other presenters have shown, that when the legislation came back it contained things that didn't seem to have been in the dialogue that took place at the community levels. So this would avoid some of that happening, if the district health councils truly represented the views of the community, the membership that they have. We would ask that you look at the legislation as it pertains to district health councils and its very specific numbers. We would suggest some changes to that.

Under section 62, part XII of the bill, section 8.1 of the act, "The Lieutenant Governor in Council" and I won't read all of that. We say that we agree with that clause except that the permissive "may" is used. This implies that it also may not. I understand that was probably put there to give you some flexibility so that at times you may not want district health councils and you may get rid of them. But we feel that they are an essential component and they should be legislated. It should not be "may," but it should be that they "will."

The Chair: If I might, Ms Havlik, there is time, if you want to get on the Hansard record, to read in some of those things. We're okay in that regard, just to make your presentation complete.

Ms Havlik: I'll start again then and say, "(1) The Lieutenant Governor in Council or the minister may establish district health councils and may specify the geographic area for which each district health council is authorized."

As I said, we agree with that except that we're a little concerned with the permissive "may" in that this also implies that it may not.

"(2) The members of a district health council shall be appointed by the Lieutenant Governor in Council or the minister." We agree with that.

"(3) In the selection of persons to be appointed under subsection (2), the Lieutenant Governor in Council or the minister, as the case may be, shall consider the importance of ensuring that the membership of the district health council reflects the diversity of the population in the council's geographic area." We would like you to add to that, "and these shall represent the interests of the diverse groups." In other words, that when they sit on the council, they're there to represent the interests of the diverse groups that they are called upon to sit on the council for.

"(4) The functions of a district health council are,

"(a) to advise the minister on health needs and other health matters in the council's geographic area...."

We agree with that.

"(b) to make recommendations on the allocation of resources to meet health needs in the council's geographic area...."

We agree with that, but I think we want you to say perhaps there that the regulations are required in that section. We understand that you can't put the regulations or the rules in the legislation, but if you would even point out in there that regulations will be required.

"(c) to make plans for the development of a balanced and integrated health care system in the council's geographic area...."

Guidelines as to how to plan and gain consensus are required in that area as well, at least to state that either regulations or guidelines are required.

In (d), reporting mechanisms to the community are required in this section. We have changed (d) and asked for reporting mechanisms to be worked out there. Work is being done in this area by the joint Ministry of Health/district health council task force. We ask that the legislation reflect regulations or guidelines which should be developed to address this function. Expeditious completion of this work is encouraged. We understand there is a task force working on that, but we really feel that (d) should state that regulations about reporting mechanisms will in fact take place.

Under (e) -- that was formerly (d) in the legislation -- "to perform any other duties assigned to it under this or any other act or by the minister." That would become (e).

Then with (5) and (6), we agree with those areas.

There are other points. We actually suggest what the purpose of the district health council should be, the structure and mandate. That's all in the brief, and the funding allocation and local autonomy.

The Chair: Again, if you want to put that on the record, that's fine.

Mrs Havlik: All right. Maybe I'll read the part under suggested changes.

We suggest that changes be made to Bill 173 which more definitively address the role of the district health council regarding its purpose, structure and mandate, as well as indicating which areas will need regulations.

(a) The purpose: The purpose of the district health council is to provide the government -- the Ministry of Health -- with long-term planning, implementation, process planning and measuring the effectiveness of programs and services of health care systems at the local level. The district health council will use Ministry of Health overall policies, standards and guidelines to produce this health care system.

(b) Reporting to the community: The district health council should reflect the will of the community it serves and should report regularly to the community at large, and we don't mean by that one annual meeting. Mechanisms for how this is to be done should be legislated.

(c) Regulations on resource allocation: Regulations are required which will assist in prioritization and the allocation of resources based on work that has already been done, and we refer you to the Comprehensive Health System Planning Commission of Southwestern Ontario.

(d) Prioritizing needs: Regulations are required regarding how prioritization and consensus are obtained, and this should be stated in the legislation.

Those are our areas of concern and our recommendations. Thank you. We're prepared to answer questions.

The Chair: Thank you very much for a great deal of specific work on the bill. We appreciate that, and we'll turn to questioning.

Mrs Dianne Cunningham (London North): Thank you very much for your presentation today. My feeling is that you've been involved probably since the 1970s and you have quite an extensive knowledge and work in a very important hospital to our region.

I would like to ask a question because I too have been involved when the health councils didn't have the same, I suppose, numbers of people working for them, and I think one of the great concerns the public have is that health dollars are in the front lines as much as possible, with people who are taking care of people. We're hearing a lot of the concerns about health councils, and we're wondering if one of the reasons for your recommendations is that you may feel that in some areas of the province, they may have gone too far. They may have too many resources. Most would consider it administrative. In your recommendations for change here, will that really take care of the balance, or in the mandate itself how are we going to balance administrative costs and front-line costs, taking into consideration your concerns about the health councils?

Mrs Havlik: The problem is that there's a lot of expertise in volunteers in this day and age now in the communities which is not being tapped is basically what I'm saying. You have superannuated teachers, you have retirees from big corporations who have taken early retirement who are looking for work. They're looking for things to do, but they're not looking to be paid for it. They want to be kept active, they want to participate, and they want their minds to keep working as they have worked in the past. I think that in our county, by us being involved, by retirees being involved as volunteers, they have brought a great deal of expertise to the county for free.

Why not tap into that and at the same time improve their health, because if they don't participate in these things, they will lose their abilities, they will go and sit in a corner somewhere and deteriorate. So you're killing two birds with one stone, as we say. You are getting something for free, good stuff, and you are also preventing ill health of those people who are sitting out there looking for something to occupy themselves. I think that's the perspective we're coming from. Why not use the talents that are out there?


Mrs Cunningham: So are you saying that the volunteers should be used on health councils as well as in the hospitals as we've known them in the past?

Mrs Havlik: That's right, and not just on the health councils, but in order to get the kind of perspective that the health council needs about the community, these people could help, and they would be unpaid staff. I realize that you need paid staff, and you said like the administrative costs, and of course there will always have to be paid staff. There would always have to be paid staff. We understand that.

We're not very clear as to how the resources have been spread out throughout the province. They may have been overloaded in some areas. I'm not totally knowledgeable about how that has taken place. But in our own county I could see where the administrative costs -- yes, you have to have some. But try to keep them at a minimum and use these other people, and you will get help that you didn't even realize was out there.

The Chair: Thank you very much for coming before the committee this morning. I think, as it's happened, we've heard a great deal about Lambton county. There are obviously a lot of people in the county who have been doing a lot of work and we thank you for it.


The Chair: I call on Mr Ken Reffell. We welcome you as well to the committee.

Mr Ken Reffell: My name is Ken Reffell, and I reside in Port Franks. Port Franks is in Lambton county. A 10-minute drive north on 21 would get you to Grand Bend, and another 40 minutes, if you want to go southwest, will get you to Sarnia, and we're right on the lake. So this gives you an idea of where I'm coming from.

I represent the Port Franks Seniors Action Club. I'm a member. They wanted me to convey the fact that they support the objectives of Bill 173. They think it's an opportunity for them to look at other aspects of the community so they can get involved. Now, they are involved with setting up tours and visits to hospitals and things like this.

If I can get back to the brief, on page 3, what was there was the words "open-ended," and that to me is a waste of money and was the wrong word because everything's there, gifts to take, and this isn't what we want. What we want is flexibility in funding.

There is a news brief attached to your package that you can look at in your own time, and I'll make a few remarks on it later on.

Well, good morning. Here we go. We do agree with the bill, as I said in the beginning. The ideas behind it are tremendous. When you read that section 1 and what they're trying to do, it sounds great, but then when you get into how they're going to do it, they don't mesh. There seems to be a lot of symbolism. The substance isn't there yet, and that's the thing I'd like to talk about.

We should design the system to serve the person, not the person to fit into the system, and what that involves is a choice, giving us a choice. And when we say choice, we mean a menu service, not just a rigid prescribed program, but we want it with a cap. We are concerned that the impact of physicians, for example -- it's vital and it's not to be omitted from any stage of the assessment or the placement of that person.

If you would like me to give you just a short analogy of that paperclip -- this is a factual thing. This isn't theory we're writing. We hope this works. This is a factual thing.

This lady has two tubes, one in her throat and one in her stomach, and every two hours she has to feed herself. She's just been advised that OHIP is no longer going to take care of that cost. Now, she's at home. She's able to live to the fullest of her life and it's in private and she's happy to do it. What they're saying to her, and a spokesman from OHIP said to her, is, "We're sorry, but we don't think you qualify for our help."

Now, they qualified that by saying: "If you join our home" -- what shall I say? -- "plan, then we can do this for you. If you don't want to do that, then you'll have to get on welfare."

So we're saving a dollar and spending $10. They say, "We'll give you this, providing that you go through two other sources," but it's still government. It would cost less if she just continues to do it herself.

So this is one of the points I'm trying to make about having it flexible.

I'm going to split my time so you get as much time as I have to speak to ask questions, and this I think will work out for the best of all of us.

The appeal: I was really surprised when I looked at the appeal. It's just unsatisfactory. It's too long. It's 30 to 35 days, and we want it three days maximum. Most important is the fragile and ill older person not travelling outside their community. This appeal should be brought down to the community so that in three days we're taken care of.

For example, if she's going in the hospital for an operation, she comes out and she was supposed to be home for three days. She can't go on a waiting list because it's going to cost a lot of money sitting in the hospital, or lying in the hospital.

We feel that if we have a flexible plan that can say, "Yes, we can look after you, and this is the way we're going to do it, at the most economical cost" -- in that first section they say that we're going to get economical service, and we agree with that; it's when these economical services say, "Oh, no, we can't look after you," and they put you aside.


I believe that another very serious part of that appeal board is that there's no human touch to it. In other words, suddenly you're not eligible and a phone call comes to you. We think a person should go out to that person and explain to them why they can't and how to get the appeal board working for you and so on.

We're suggesting that an appeal board have only four members, and not more than two should be medical personnel. There should be an ombudsman involved, an outside party, a third party, if you will, checking on the accountability of that board in relation to the condition of the person.

I think I've made my points, and if you'd like to take over the questions, I'd be glad to answer them.

The Chair: I just wanted to make sure there wasn't anything in your written brief that you hadn't said, just to make sure we get it on the record, because we do have some time if there was anything you'd like to add.

Mr Reffell: Oh, we do have the time? I thought I had seven minutes.

The Chair: No, you have 15. I just want to make sure you can get all your points out.

Mr Reffell: I cut them back for that reason.

The Chair: If there is anything else there that you wanted to include, you have a few other points there.

Mr Reffell: Okay. The available service and programs do not define consumers' needs. This goes back to my opening statement about, don't put the person into the service, have the service suit the person. This is what it means by it doesn't define the consumers' needs. It doesn't look after those needs. It's too rigid.

And flexible funding: That is, for example, that lady in London, Mrs Rowe, who has cancer and has all these tubes in her.

Another point I'd like to make is that multiservice agencies should help make other referrals on the appeal board, and service must be provided until the decision is made by the appeal board. We don't just leave the person somewhere waiting for the service.

A neutral facilitator is very important.

I think those are the points I wanted to make.

Mr David Winninger (London South): Thank you for your presentation. You seem to agree in principle with the single access point to an integrated continuum of services, but what I hear you saying is there needs to be more flexibility and consumer choice involved.

Mr Reffell: Yes.

Mr Winninger: You also seem to support a process that is locally driven, locally planned, locally managed, locally funded and providing for delivery of services in a manner that's responsive to the community.

You're one of the first I've heard who has actually addressed the appeals procedure in any kind of focused way. I thought I'd note firstly, and then put a question to you, that there's nothing that I can see in the legislation that would prevent the MSAs from having their own alternative dispute resolution procedures or internal complaints procedures that might be able to deal with refusal of service or refusal of a particular kind of service, short of actually proceeding to appeal. So there is a possibility and potential there for a local resolution to a problem.

At the same time, I see some value in having a standardized form of appeal to the board, similar to that that prevails with nursing homes and homes for the aged, so that you can have some kind of consistent decision-making across the province which will offer precedents that people can rely on in the future.

I just wonder if that kind of balance between local alternative dispute resolution mechanisms and internal complaints, and yet a unified system of appeal to the board, would suit your concerns.

Mr Reffell: I think it's an excellent idea that you make, but I'd like to get accountability into that decision, an outside body. I think that if there is an excellent assessment tool in place, we wouldn't need this board at all. If we had professional, prudent decisions made, we could do away with it and save a lot of time and --

Mr Winninger: One hopes that would be the model for the MSAs.

Mr Reffell: Yes.

Mr Winninger: One other thing I noted, and you probably did too: Section 37 of the appeals section said if a person is unable to attend a hearing before the appeal board, at that person's request the appeal board members can actually attend upon the party requesting the hearing.

Mr Reffell: Right, absolutely. I think that's a good idea.

Mr Winninger: Presumably the appeal board can be responsive to individual needs.

Mr Reffell: Well, if that is the case, yes. But it's the time element that's so important. If it's locally, it'll be three days, and if they're receiving the service then it can be five days. But we want it quickly, again. But I think the appeal board should be almost done away with if the proper tool is in place to make the assessment and the placement and that's done by professional, prudent decisions. This is an extremely important issue, I think, and one that deserves a great deal of thought and discussion.

The Chair: Thank you very much. I think, as Mr Winninger says, you have really focused on that appeal procedure and we appreciate the points that you've made. Thank you again for coming before the committee.

Just before calling the next witness, members of the committee have also received a number of written submissions that have been sent in and the clerk has set out for you.


The Chair: Our next presenter is from the Oxford county home care program. Kathy Desai is the director. The clerk is passing out a copy of your presentation. Welcome to the committee and thank you for coming.

Mrs Kathy Desai: Good morning. I am Kathy Desai. I'm the director of the Oxford county home care program; however, I don't have anybody's permission to represent them or be representative of them today. But I think that Mr Reffell and I will form a new group because I have exactly the same thing to say as he does. We haven't met one another, but we could have done our presentation together.

The Chair: I'm glad we brought you together.

Mrs Desai: I thank you for the opportunity to comment on Bill 173, An Act respecting Long-Term Care. It is with a great deal of optimism about an improved system, balanced with a nervous scepticism about the possibility of implementation, that I encourage you as a committee in this very necessary work.

In my view, the intent of the legislation is progressive and well thought out. It reflects a balance of academia, provider knowledge and consumer wisdom. There are, however, opportunities to improve the possibility that this intent will remain intact throughout the implementation. I hope to highlight some of those opportunities by organizing my remarks into three areas: concerns about the overall system of health and social service, the MSA itself, and the individual consumer.

The overall system: It is my belief that the single most important organizational concept in the reform is integration. The minister has spoken of a move from the broker model to the integrated model. Academics who have looked organizationally at long-term care believe that integration is the key to success. Through integration, efficiencies can be realized and appropriate use of various supports, services and beds can be made.


The consumers want less specialization and fragmentation, which is more integration. To support the values of efficiency and effectiveness, we need to support integration. In the short term, integration is within the MSA, but the long-term goal needs to be greater integration along the entire continuum of care. The integration needs to occur first at the policy level and then at the service level. The most significant integration in this long-term care reform is the link the PCS will provide between long-term care institutions and the community.

The Chair: I'm sorry. Just for the record, PCS?

Mrs Desai: Sorry. Placement coordination service.

This will be the first real opportunity the community services have to provide an alternative to institutional care and the first real opportunity to reallocate dollars.

My issue here is that the integration does not go far enough. Short-term community-based care has no similar placement coordination services link to acute care hospitals, so envelope funding could lead to the erosion of long-term care. At the policy level, an integration of Bill 101 and Bill 173 etc, maybe the hospitals act, would set the stage for integration at the local level.

It is important for implementers of the act to understand the true significance of integration and the longer-term vision of integration, so I would argue that it should be written into the act, perhaps in the purpose and perhaps under 1(f) where we talk about efficiency. I believe it also needs to be understood that the comprehensive health organization is the most integrated model suggested and therefore has the greatest opportunity to be cost-effective across the continuum.

The MSA: The section of this act that applies to the MSA itself treats change as though it were a clear rejection of the past. However, it does not ensure that the future will enable individuals to be more independent with respect to how they solve problems.

By including persons experienced in the health services field and persons experienced in the social services field, as demonstrated in 11(b), you will encourage a balance of health and social assessment, and this is long overdue. It just is not good enough. Empowerment is an idea whose time has come, and it will happen. It will happen more readily if the structure supports the function.

All expert models promote learned helplessness, not just the medical model. The learned helplessness results from the attitude of the help giver and the deference to care giver authority of the help seeker. Past change did not go far enough or deep enough, and this does not either. Cutting out the past and having new people deliver the old will result in more of the same, only "new and improved." What we want is transformation that recognizes the past in the same way we recognize the present and the future. New attitudes develop with new information.

It does not matter what group becomes the sponsoring body for the MSA; they need to be empowered and they need to understand how to enable other people. They need to understand what structure will support professionals and others in using the appropriate models. The effectiveness outcome will be directly proportional to how independent the consumers are with respect to their own health, not what professionals are employed. The oppressed don't necessarily make any more empowering leaders than the oppressors. Everyone in the past, present and future model needs new information. The whole idea of interim MSAs needs to be thought through so that the encouraged development is consistent with the long-term vision of integration and empowerment.

Individual consumers: This act wants to ensure accountability to the consumer, but on every mention of the real client, there is an assumption that the help seeker is less powerful than the help giver. That is an expert model. That leads to dependence and learned helplessness. This is most obvious, as the former speaker pointed out, in section 20, the service plan, and section 32, the appeal. The purpose could also refer to accountability in a more real way, more directly related to clients, and I think Mr Reffell said that best.

Section 20 does not ensure a contract reflective of a partnership. To "assess the person's requirements," as it states, infers the expert is the help giver. An assessment tool will be rendered useless if it is not administered in an empowering way. It is how you do it as well as what you do. We cannot cure; only the clients can do that themselves. It is the questions we ask and how we listen to the answers that becomes vital to matching needs and resources.

I don't want to sound overly simplistic, but number 3 in this section should be first, and the section 1(a) should read more like, "The person participates in the process of assessment, and the outcome of the process is a plan reflecting mutual goals." This is a contract. This is a partnership.

The whole idea of timeliness and a waiting list is pretty oppressing as well. If there is a CQI process that includes consumers, this needs to be individualized in the local MSA. I personally think waiting lists are a symptom of a system that does not know how to prioritize and a system that believes there is more money than there is. We need to be more accountable in defining need so there will not be waiting lists, rather than legislating waiting lists.

The language in the appeals section, section 32, does not reflect mutuality in the plan of service. It clearly allows the provider and/or agency to be the expert. It also infers that the expert opinion can be overruled by the superexpert. The goal of a client-driven model would be a mutual agreement, perhaps for disengagement from formal resources. This appeal process makes the agency accountable to the government rather than the person, and that is not transformation. I thoroughly support an appeal process. The wording is very challenging, but it has to reflect a partnership.

In summary, the policy direction is a good one. I'm very happy. It forces a new relationship between partners in in-home services. Together, the two bills link long-term care facilities to in-home services. The act removes the competition within the MSA so energies can be focused on the delivery of services. It also recognizes social as well as health needs. However, the issues of cost-effectiveness and quality of service are not sufficiently addressed. Cost-effectiveness could be enhanced by more definite language around integration as well as more horizontal and/or vertical integration. The quality of service could be ensured by making the agency accountable to the people it serves, or making it client-driven. The language in the act does not encourage transformation or even reform; unfortunately, it is passé.

Thank you very much for the opportunity. If you have any questions, I'd be happy to try to answer.

Mrs Caplan: I'm really impressed with the presentation you've made, Kathy, and pleased that you've come before the committee today.

I want to just explore with you a minute some of the concerns you have around the lack of integration within the proposed model, but also seek your advice. It seems to me that under the comprehensive health organization model that you referred to, or any other kind of an integrated model, direct service delivery is not the only option. In fact, there is an opportunity within that integrated model for purchase of service, which would allow for competition, best practices, benchmarking, cost-effectiveness. You didn't address that. What I heard was that you felt the MSA, as it is defined in this legislation, as the sole provider, might be acceptable. Could you just expand on that?

Mrs Desai: I've tried to form my opinions about this related to Michael Rachlis's work and Carol Austin's work. As you know, I run an agency that is a case management organization, and I've tried to think of it from that perspective as well as from the cost-effective perspective. Everything I read makes me think -- and this is different than I thought three or four years ago -- that until there is one body accountable for the entire spectrum, you cannot realize efficiencies from the more expensive services to the less expensive services.

The way Carol Austin defines "authority" in case management is the breadth and scope, the scope and span, of the case manager's role. The least effective authority the case manager can have and the least effective efficiencies she can realize, then, are when she's just controlling contracts on a fee-for-service basis with providers. The most effective span of control she has is if she follows the client from entry to the system for ever, because then she has authority to look at utilizing the least expensive services first.

So I've come to think that competition has, in our mind, some value in controlling costs in the short term. But it currently is my view -- but my view changes every time I have a new piece of information -- that competition is not the most effective way to get efficiencies over the overall system. It's also my view that competition has in some ways held the community back. It doesn't exist in other areas of the health care system, and in some ways it has not enhanced our ability to improve community services.


Mrs Caplan: Within that fully integrated model where you had the options as to how you would deliver, based on your philosophy, what sorts of outcome measures and evaluations would you use to ensure (1) the accountability, and (2) the fact that you were getting the most cost-effective? I ask that question because we have some models that suggest that when you have one big bureaucratic monolith, in fact it's less efficient and effective than it could be or should be.

Mrs Desai: This critical mass and how big you can be and still maintain a client-driven consumer focus isn't something I've totally sorted out, but it's a very critical issue in giving the interim MSAs the go-ahead, because if we're going to have a long-term vision of a comprehensive health organization, then you need to develop around populations that would be right for that. On the other hand, if we're not going to see total integration as our long-term vision, then it's quite a different population you would need. Whatever decisions you make now, we're going to live with for a long time, so I think we need a common perspective about whether we believe integration is the way to get efficiency or not.

In terms of this accountability, and this may be overly simplistic, but it's my view that if we did transform, if this reform is radical enough -- and by radical I mean going to the core, so you turn your organization inside out; you begin to ask completely different questions of the client. It's not, "What is your past health history and how do I match services to needs?" It's: "Who are you? What was your picture before you were sick? What is your picture now and what do you want your picture to look like in the future?" So if you begin to say, "Tell me your story," instead of, "What's your diagnosis and what services do you want?" it is my view that's accountability, and it's my view that would be cheaper than what we're currently doing, because the mindset of the provider goes to these minimums and maximums, and that's not where the consumer is coming from. If you ask them what they need -- need and want ultimately in an ideal world are the same thing, but we do need a lot more thought right now about what need and want are, and if the consumers want more than we have to give them, then I would say they got that from the providers, so the providers have to take the initiative in changing that around. I mean, we've encouraged them to go for boxes because that's how we fund health care.

So turning it around, that accountability comes from really being client-driven. I'm not afraid of being client-driven if we really do turn the system around, but it's hard in the interim when you're half and half, when you need an accountability structure to control what we think would be uncontrollable costs and when you're trying to transform. I don't know if you can do this halfway thing, so I would say go for broke.

Mrs Caplan: Thanks very much. That was very thought-provoking and very helpful. You've raised a number of issues that I don't think have been raised before at the committee. How the system can be reoriented so that it is client-driven, with the patient's interests and the client's interests coming first, I think is ultimately one of the goals that I'd like to see as part not only of long-term care reform, but any health reform that is brought forward. Thanks again.

Mrs Desai: It was nice to have an opportunity.

The Chair: With the committee's permission, we have with us today also the member for Oxford and I'd like to allow him one question.

Mr Kimble Sutherland (Oxford): I don't really have much of a question. I think some of the questions Mrs Caplan asked pursued some of the areas. The accountability aspect was certainly one.

Let me just say that I'm very fortunate to have Kathy's advice on a regular basis as one of several providers who provide some very innovative thinking on where we should be, and I would suggest maybe out ahead of many of us on where our thinking is on how to deliver health and social services and the work to integration.

I guess my only comment is whether you wanted to address the issue -- we certainly heard some concerns about how volunteers fit into an MSA model, in some sense that volunteers may be lost in that type of model.

Mrs Desai: I've worked for volunteer organizations in the past and I recognize the value that volunteers have to the entire system. Being in a community, I've always been jealous of the volunteers and the money that acute care institutions could raise in competition with us. I don't have any sense that volunteers would be any less active in a system regardless of how it's funded. Volunteers work because they want to contribute something, and it depends on how you recruit them; it depends on how you reward them.

Certainly, the volunteer sector has done a lot better job, perhaps, of acknowledging their contribution and it's been a much more obvious, innate part of the organization. But if you set it up right, there's no reason why volunteers wouldn't contribute to the MSA the same way they contribute to foundations, hospitals, whoever. It's all the same people working in the same community. It's how you treat your volunteers that keeps them with you, and how much satisfaction they get out of what they're doing. It's not what organization owns them. We should forget all this organizational stuff.

The Chair: Thank you again very much for coming before the committee this morning.

Mrs Desai: Thank you for the opportunity.

The Chair: Are the representatives from the Belle River and District Community Council here? No.


The Chair: Ms Anne Fowler is here and we can proceed with her presentation, and then should the Belle River representatives come, we can go back. I believe as well that the Victorian Order of Nurses are here, so we will go on to them next if the Belle River group is not here. Ms Fowler, thank you for coming before the committee.

Ms Anne Fowler: I sincerely appreciate the opportunity to speak to the standing committee on social development, and I speak to you as a consumer, a care giver and a case manager.

It is important to me that you consider my perspective as a consumer and care giver. I am the only daughter who lives in the city where my parents live and they are almost 80. My parents are alert, capable and independent and they cherish the dignities of privacy and autonomy. But during recent years, when one becomes ill, even for a short term, the stability of the situation is precarious and my responsibilities change drastically.

It is also important that you acknowledge my opinion as a case manager, as a person who has a unique perspective because of extensive experience working in the field facilitating access to community-based support and in-home services.

My life situation, including personal responsibilities and 25 years working in the health and social services system, certainly impact on my positive thoughts and worrisome concerns regarding Bill 173.

The legislation: It definitely has strengths. I commend the ministry on introducing legislation that reflects a shift of philosophical and service delivery perspectives. The attempt to facilitate access and to enable flexibility in service options that indicate a greater sensitivity to the person's needs rather than the system's rules are welcomed. The emphasis on client empowerment and self-direction are beliefs that have always been a guiding principle in my practice as a case manager. The intention to support the local district health council as the community leader in MSA implementation and decision-making is essential to ensure that this process is community-driven. I acknowledge this legislation impacts considerably on the person's access to the system, a skilled assessment, an effective service plan and appropriate service options.

My concerns as a consumer: I support the emphasis on simple access and agree it can be approved, but I urge the ministry to take great care that the initial focus on perceived need and task does not lead to inappropriate and excessive assessments prior to appropriate service delivery. This would only increase the risk to the client and the exhaustion of client and care giver.

An example is a request for help with a bath. It sounds pretty simple, but in fact a home support worker or a nurse might be quite inappropriate in this situation. Maybe, on careful questioning based on a broad health needs knowledge base, it might indicate that an OT is required because there are environmental modifications that are required. Simple requests do not necessarily equate to simple need and simple solution, so do not underestimate the complexity of needs or the variables of your MSA target population.

I agree with the ministry's believe that different models of case management are required and that some clients or care givers wish to provide their own. I recognize that the "well" physically disabled may only wish to initiate annual contact or maybe none or maybe just involvement with problem situations, but one must realize the well person has greater energies and strength to focus on directing coordination activities.

The frail elder with health concerns and without family in town may wish regular contact, but this too is a model of self-direction.

I've met many care givers who are focusing their energy on supporting the client, and one more responsibility would be considered too many. As a consumer, I request access to components of service coordination to the degree that I determine.

Something else I wanted to say was there really, in my experience, has not been a public education program by the ministry to the citizens of this province concerning the health and social services system. They know about the nurse from billboards and TVs, about the physiotherapists in the yellow pages and at sports events etc. Many consumers know little about the human resources, including case management, except when they experience a system-generated service restriction. Misconceptions and lack of information mislead consumers and jeopardize the ability to determine the issues and to make decisions.

Now, my concerns as a care giver: I'm appalled that the case manager or service coordinator may be determined by the "problem" or the "need" of the month. I want to be able, as a care giver, to contact an expert in assessment and coordination. I want someone who is committed to building on strengths, meeting needs, advocacy, communication, linking and coordinating services.

The assumption that all service providers have the time and the expertise to focus on quality service coordination and to ensure continuity and to be available to the client and care giver is erroneous. Canadian-based research evaluating this approach is not available. This assumption, transposed to other settings, infers that any teacher is skilled and knowledgeable to teach any student in any grade, or any engineer can work in any work setting. This thought process seems absurd. Why in the health and social services system is there the lack of recognition for the skills, knowledge base, expertise and role expectations in the unique and the different roles?

As a care giver, I don't have the time or energy to deal with system inadequacies, to search for the right answer, to ensure I'm asked the right questions and to get the right service provider. I expect the MSA staff member who connects with me via phone to have the skills to do this efficiently.

My concerns as a case manager: The ministry has neglected to include case management as a core service and again is demonstrating a continued undervaluing of the skills and knowledge required to complete this function well.

I have the utmost respect for service providers, specialists in their scope of practice. I value the skills, commitment and knowledge that community support, health care and social service providers possess. But to assume that all service providers have the skill, knowledge, interest or mandate to provide this unique role is folly. Many service providers emphasize the assessment of illness state and interventions re the diagnosis and disease process. And their expertise in this is valued. It is important not to misuse their time and specific expertise, a misuse that can only lead to escalating waiting lists.

There's no emphasis in Bill 173 regarding the collaborative efforts of community service providers -- the team. All are accountable, but one needs to ultimately be responsible for ensuring a simple resource contact exists and that the smooth coordination of services occurs.

Fragmentation within the system will decrease and integration increase when the ministry more clearly defines approaches to access, assessment, service provision and also ensures that service evaluation, outcomes and cost containment are integral in these considerations.

So in summary, as a consumer, a care giver and a case manager, I acknowledge the system requires philosophical and organizational changes. I urge the ministry to recognize that simple service need does not equate to simple need; it merely means one service is maybe adequate for that day or point in time. I expect the right to access simply and quickly a holistic skilled assessment, continuity and consistency in the contact person and expertise in service coordination.

I recommend that access move simply and quickly from information-giving to assessment when need beyond clearly defined community support service is indicated; that the assessment be client- and need-focused from a holistic perspective rather than reflect task and specific clinical emphasis; that case management be listed as a distinct professional service.

I recommend that the decision to delegate the case management/service coordination function be made in consultation with the client following assessment that clarifies, with the client, the needs and the actual service provider who is required. I urge the ministry to commit to a public education program that includes not only information about system changes and service availability but also about costs and the rationale for cost containment.

Thank you for this opportunity.

Mr Jim Wilson: Thank you for your presentation. You bring to light what many presenters have also brought forward to this committee: concerns about the assessment process.

I can tell you that we don't really know at this time -- and are unable to really find out from government, because they're still looking at this area of, as you know -- who or where or how assessments will be done or what the eligibility criteria will be. That, to be quite frank, does make it quite difficult for us as legislators to really make an informed decision about this legislation given that so much of it is not spelled out in the act, because assessment, as I think you'd agree, is the key to this whole thing. It's also the key to things like whether or not the particular consumer has to pay for certain services. When the plan of service is developed, it's absolutely crucial that proper assessment be done.


So I'm just going to ask you to try in as simple a way as possible to give me your vision of what the model should be. I want to get that on the record. Particularly I'm interested in trying to picture how this will be done by the MSA: whether it'll be one person who takes the initial assessment and then the client, for various reasons, whatever they may be, is then referred to a multidisciplinary team for assessment, or how will this be done and how will it be done within an MSA, given that a lot of these people are going to have to be on staff because of the 20% rule.

Ms Fowler: That's correct. I guess I can see it evolving actually fairly simply. I certainly have read the recent -- and I must preface my remarks by saying I've read the most recent infrastructure working group documents related to the MSA, and in the last two weeks they have been dealing with service coordination etc. I have to say what's in those documents pretty well scares me as a consumer. I'm truly distressed, especially by the screening and the intake process that is being suggested. It's extremely convoluted.

I really think there can be a screening process that is extremely simple, and for the person who is well or even not well and clearly defines a need that's very specific and community-support-related, the actions may occur right then. But for the majority of the target population that I've had experience with, and I know within home care there are over 50,000 on every single day who are receiving in-home services that way, I think then it needs to move to a broad-based assessment. It's very intimidating to have numbers of people go into people's homes. One of the privileges in working in the community versus, say, the institutional sector where I have worked, is that nobody needs to let you in their door. They really have the right, and it's wonderful. That was one of the most liberating experiences I had in the community.

But I think one person with extensive skill could very simply do a broad-based assessment to establish what service is the real need for sure, and in consultation with the client. I can't imagine not feeling a partner with the client. In fact, they are the ones who should be in control always. I'd demand it as a client or consumer. I wouldn't tolerate any other kind of method of interaction; I just wouldn't. So I wouldn't think of treating anyone else that way.

But I think it can be done simply. I think there can be an initial screening and then go to a broad-based holistic type of assessment and then go immediately out to the specialists that are required. I think it would be great to have for consultation purposes a multidisciplinary team or a geriatric assessment resource. There's a variety of resources that would be helpful for that person to be able to consult, but I don't think the client in the home has to be intruded upon by numbers of people.

The Chair: Thank you, again, very much for coming before the committee. I would ask again if the representatives from the Belle River and District Community Council are here. Going once. Okay, we'll see; they may have been delayed.


The Chair: I ask the representatives from the VON if they'd come forward. If I could say to committee members, if they wish to do what I'm going to do, having been in the chair for a couple of hours, I'm just going to stand and stretch.

Mrs Caplan: Where's the music?

The Chair: Yes, we need the Blue Jays team, or something.

Mrs Haslam: Blue Jays? What are they?

The Chair: Down the road.

Welcome to the committee. We know that you are here representing a number of branches of the VON. For the information of committee members, by grouping a number of branches together, we're providing more time. We just thought that would make for a more concentrated presentation and perhaps allows us to ask a few more questions.

Thank you for coming, and if you'd be good enough just to introduce yourselves and then please go ahead.

Ms Janice McCallum: Good morning. My name is Janice McCallum. Sorry for the confusion on the agenda, but I am doing the presentation today. I'm the president of the Middlesex-Elgin branch, which is the branch that is located in London. With me is Kathy Bamford. I've been thinking about the things that Kathy Desai had said. They were quite provoking. Kathy Bamford is the executive director of the Oxford branch and she will help me with the questions, particularly related to anything in the branch program delivery area, but I will be doing the presentation.

The Chair: For the Hansard record, could you just note the VON branches?

Ms McCallum: Yes, I was going to go through the branches. The seven branches that we're presenting on behalf of today in a joint submission are the branches from Chatham-Kent, Grey-Bruce, Middlesex-Elgin, Oxford, Perth-Huron, Windsor-Essex and Sarnia-Lambton. So there are actually seven branches and they make up the southwest region.

The seven branches of the VON of the southwest region of Ontario appreciate this opportunity to present their joint submission on Bill 173 to the standing committee on social development. You may be aware that VON has a 97-year history of keeping people in their homes through the provision of community health and support services. With this experience, we recognize the need for reform and we support the Long-Term Care Act's purposes and general directions.

Here's a little bit of background for you. VON is a not-for-profit, voluntary health care organization that addresses the health and social support needs of people in Ontario through services provided by nurses, other health professionals, home support service workers and volunteers. I'd like to add that VON is a national organization and we are chartered through VON Canada.

The county configurations of branches that we're representing today include the makeup of the southwest region. They coincide with the names I identified for the branches: Chatham-Kent, Grey-Bruce, Sarnia-Lambton, Middlesex-Elgin, Oxford, Perth-Huron and Windsor-Essex. Our 1,213 employees and over 2,000 volunteers service expansive and diverse communities from Manitoulin Island to Lake Erie, Lake Huron to Waterloo region. In 1993-94 we provided 767,000 nursing visits 24 hours a day, seven days a week to the local home care programs. Last year we delivered over 82,000 meals, we provided close to 30,000 hours of volunteer visiting and 12,500 adult day centre days for those in need, and those are only examples of the various services provided.

VON is founded on local volunteer community boards which oversee the delivery of services in partnership with local communities, clients and other providers. As a grassroots not-for-profit organization, we support local needs and collectively have networked to realize the benefits of standardization for efficiency and effectiveness. For example, VON Canada has assisted the branches by the development of program standards, and while some branches such as Grey-Bruce provide only nursing, as the home and community support agencies meet other needs, most others, such as Oxford and Chatham-Kent, provide additional services like adult day programs and volunteer transportation. Two branches continue to sponsor the home care program -- that's Sarnia-Lambton and Windsor-Essex -- and three provide placement coordination.

Other services include foot clinics, respite care to developmental handicapped children and adults, information services and palliative care. By our holistic approach, encompassing health promotion and disease prevention, our investment in the health and wellbeing of people is for the long term, enabling individuals, families and communities to maximize their full health potential in the comforts of their home and community.


VON recognizes the need for reform and is actively involved in the collaborative planning required to implement an enhanced community health and support system that will be able to provide a quality continuum of care within the limited resources available.

Our brief is going to address four areas and they are outlined. I would like to talk about need assessment versus choice, local uniqueness versus standardization, an ideal concept versus reality, and volunteerism. I recognize that these are themes that you've been hearing.

Firstly, need assessment versus choice. A standardized approach to client assessment shall ensure better consistency in the determination of need. It is clear that the collective absolute need of individuals served in the long-term care system outweighs the ability of the system. Hence, we must have a clear way of determining relative need within resource limitations.

The management of waiting lists, as was outlined in the legislation in part VII, section 21, must be more than a queue for service. There must be an element of triage to ensure those most in need receive the necessary support services to reduce crisis situations. Within available resources, consumers requiring services to promote health and wellbeing should have a choice of needed services delivered in preferred locations by preferred providers. Subjecting individuals to a forced prescription of care is neither helpful nor cost-effective.

Communities may have to decide and limit local choices available to those affordable. For example, a community may not have a critical number of individuals to provide a specialized adult day program to persons affected with Alzheimer disease or physical disabilities and must decide whether to transport the people to another program to receive the specialized care or to provide an all-encompassing program. This presently occurs in the south rural area of Oxford county.

Individuals in need of only one service, such as Meals on Wheels or home support, should have access to the service without being subjected to a complete assessment process. Individuals who know they need respite care or Meals on Wheels should be able to access this service directly. Should they not be eligible, they should have the option of purchasing the service without affecting the funding envelope. The reform needs to support a system of self-reporting and self-application for services, diverting professionals to more complex cases requiring clinical skills. We know many individuals could complete much of the information needed at the time of assessment, given a user-friendly tool. We question the direction of the legislation regarding compulsory needs assessment by MSA staff for eligibility for all services.

We recognize and value the role of physicians in meeting medical needs and their contribution to the health and support team within the continuum of care. We believe persons receiving services are entitled to the rights that are outlined in the legislation, in the bill of rights for persons receiving services. Our VON philosophy respects the rights of individuals and believes that individuals have primary responsibilities for their own health. Direct funding to consumers or care givers to purchase services directly or from the MSA would promote responsiveness to consumers by MSAs.

We believe a reformed long-term care system must support equity and have balance between need and want, local community uniqueness and creativity and provincial standardization and equity, as well as balance the concept of an ideal theoretical model with the given realities of the day.

I will next address local uniqueness versus standardization. The VON recognizes the need to build on local uniqueness and yet provide enough standardization, as referred to in part I, section 2 of the legislation, to provide efficient and effective service as well as equity between communities. We do not yet know the outcome of the present capping of home care budgets and need to continually assess the impact of these changes while in transition. To accommodate for local variances, the new multiservice model must be flexible enough to meet the needs of residents and yet consistent with provincial guidelines to promote quality and ensure equity.

It would appear that it is the intention of the government to create multiservice agencies province-wide that will result in the total amalgamation of the current agencies that provide community-based services. There is an important need for flexibility in the implementation of the MSA and the opportunity for communities to develop models that meet their unique needs. We are recommending that the province accept alternatives to amalgamation, as arrived at by communities, that may include a federation of agencies or other models to achieve a multiservice system and to achieve the goals of long-term care reform.

From the consumer's perspective, we accept there is an urgent need to integrate at the front-line level of service delivery and to simplify access to needed services. There is no doubt that service providers can work as a team, sharing common assessments, charts, care plans and values. Through these efforts, duplication can be eliminated and better coordination can be achieved. In many of the VON branches, interagency committees have been established already to immediately tackle these issues.

Additionally, community agency sponsorship avoids having another level of government or agency board or commission of government, such as health units, sponsoring the MSA when it may well have other priorities and therefore may not give the MSA the focus it deserves and requires. The selection of individuals who make up the board which governs the MSA should be locally determined to best meet needs for the local community. It needs to reflect ethnic and cultural diversity, for example, in Kent county, where there may need to be representation from, among others, the native and French communities. We are recommending that the standing committee on social development support our request for flexibility by amending part VI, subsection 15(2) to remove the four-year limit on transition to a fully amalgamated MSA.

Our third point is ideal concept versus reality. The fully integrated multiservice agency is an ideal concept to create a one-stop shop for those in need of long-term care services. Given different local environments, we believe the governance and service delivery models must vary to best meet the needs of communities and service utilization patterns. Many communities such as Grey-Bruce do not have a significant number of provider agencies -- seven including home care -- and the access, coordination and integration of services could be achieved within a cooperative endeavour without dismantling the present system.

The Windsor-Essex branch recently formed a partnership with the local Red Cross agency and home care program in the interest of system improvements, such as a shared client record. In Grey-Bruce, the district health council has put aside the MSA governance issues to deal with practical improvements to the system, such as one assessment tool. We believe the amalgamated MSA has yet to be tested.

During transition, it is important that the current solid foundation of community supports not be destroyed in achieving redirection goals. We are concerned about creating a bureaucracy which is inflexible and diverts dollars from individuals in need of care to an unnecessarily complex and costly system. We believe a partnership MSA with a federated board is more likely to experience a synergy of federated volunteers. Shared recruitment would improve the choices volunteers have as well as shared training, particularly in specialty areas. These are achievable without total integration.

Critical to the success of a reformed system is the development of databases which eliminate the costly present duplication of information and assessment. This has been one of the most significant handicaps of the present system. The joint VON-Ministry of Health direct billing project is an example of how collaborative endeavours result in efficient and effective systems. The investments the government have already made in this area have been significant, and experience gained needs to direct future improvements required.

An automated management information system using data standards province-wide is necessary to allow comparability on quality management indicators. Sharing information between MSAs and publication of comparative data encourage responsiveness, cost-effectiveness, collaborative problem-solving and innovation. Experience within VON has proven this without taking away any local authority.


The realities of a fully integrated MSA become extremely complicated within the human resources area. VON, along with other long-term care community health and support service providers, has requested from the ministry protection for non-union staff similar to the protection afforded under successor rights in the Labour Relations Act for unionized staff. We are requesting that the committee make a strong recommendation on behalf of non-unionized employees for equal protection with unionized employees as this new system is created.

Critical to the success of the new system is the transfer of the valuable skills and experience of all community agencies that for many years have made a significant contribution to our communities. In the interests of those receiving care, we hope current staff have equal access to jobs in any new MSA.

Severance costs for non-profit long-term care community agencies could be significant. In contrast to for-profits, all moneys of not-for-profits are returned to service in the community and thus few organizations have equity to pay severance.

My final point is in volunteerism. I am not a paid staff member of the seven VON branches. I am a volunteer. I've been a member of the board of directors of the Middlesex-Elgin branch for seven years and I'm currently in my second year in my term as president of the board. I'm also an elected representative to the provincial governance structure in the VON, which we refer to as the constituent assembly, and I sit on the executive of that body. When people ask me how much of my time these activities take, I tell them that I'm afraid to add it all up. It would be too scary to know.

Why do I volunteer? I am a very busy person. I work full-time in a demanding middle-management job, I have three young children and in my career I don't make business contacts through volunteering, which is often the motivation for many, so it isn't enhancing in any way that aspect of my life. I became involved as a volunteer with VON because I believed in the value of that particular organization. Unlike one of the previous speakers, I do believe that volunteers are quite committed to a particular organization because of the values and the things that organization represents. I felt I could help them to accomplish something worthwhile and that it would make me feel good, and that was why I did it. VON is a charitable organization as well as a not-for-profit and it gives back to the local community.

Across Ontario, there are thousands of volunteers like myself helping such organizations. Because this volunteer involvement is so tightly tied with agency identification, I wonder how successful a multiservice agency will be at recruiting or replacing those hours of volunteer service and commitment.

In summary, the VON is committed to the principles and ultimate goals of the government's long-term care policy. We strongly support the need to further develop a cost-effective quality system that will increase consumer participation in decision-making, simplify access to service, reduce duplication and improve coordination of service. The question is how to get to the redirection goals without destroying the solid foundation in place today.

The VON of Chatham-Kent, Sarnia-Lambton, Oxford, Middlesex-Elgin, Grey-Bruce, Perth-Huron and Windsor-Essex counties request that this act and any regulations to the act be flexible enough to allow for partnership models for MSAs involving a federated board and an integrated service delivery model.

Thank you very much for your time.

The Chair: Thank you very much. Just before turning to questions, I'll just tell members of the committee that the representatives from Belle River are here, so after Mr Winninger we'll move back to Belle River.

Mr Winninger: It's indeed a pleasure to hear you present today and also to have met you at my office yesterday. You gave me a bit of an inkling as to what you were going to say today. In connection with two of the many different points you made, I wonder if I could ask you what value you see in removing the four-year cap on transition to a fully amalgamated MSA. That was one of the requests you made in your presentation. Either of you.

Ms McCallum: By enshrining in the legislation that there is a time frame of four years to a fully amalgamated MSA, you prevent the possibility of partnership or federated models. For many communities the ultimate definition of an amalgamated MSA would not be what would work best for that community, and I think that is some of what you've been hearing.

The legislation should be written in a permissive way so that it does allow for the communities, through the district health councils and the long-term care planning processes, to design the MSAs to suit that community. For many the amalgamated would not work. That's why we're recommending that time frame be taken out. It does allow for either to occur, depending on the community.

Mr Winninger: I see. A second point was your concern about the individuality of the organization, such as the VON, being swallowed up in the MSA. I know yesterday I drew your attention to page 28 of the Partnerships in Long-Term Care guidelines. There was a very useful suggestion, I thought, made there, such that an agency that has a profile, as the VON has had over the last 100 or so years, could promote and identify itself perhaps as, "The VON, a proud member of the London-Middlesex LTC multiservice agency." Would that not respond to your concerns about identity of volunteers with a particular organization yet it's also a part of a larger multiservice agency?

Ms McCallum: I think what you're identifying, David, is somewhat in conflict with what is in the legislation. Some of the early discussion documents did seem to allow for more of a partnership rather than a fully amalgamated integrated model. What the legislation is saying is that within four years there will be a full amalgamation. As Mr Wilson is saying, our staff who work now in the services that are provided to clients who would be under the MSA would no longer be VON staff. That's why we're concerned about the security for their positions. Therefore, the VON as it exists today would have to be quite different. It doesn't mean that we couldn't exist, but we couldn't be part of the MSA as this legislation is drafted.

Mr Winninger: Originally the VON was accorded a little additional time because of all the chapters. I know Kimble has a quick question, if there's time.

The Chair: I'm going to allow a few more because of the fact that we're dealing with seven organizations, but I'll go next to Mr Wilson.

Mr Jim Wilson: I just want to follow up on this point, because it's important that everyone know that what you've said is correct, in spite of all the wishful thinking that the groups that are being swallowed up by the MSA are somehow going to survive and have some distinct identity so that they can continue their individual missions and purposes and objectives and retain their volunteers. It's simply not the way this legislation reads, nor is it the model. Eighty per cent of services have to be delivered by the MSA, and those people become employees of the MSA.

I want you to know that so far we've had discussions with the government about what happens to all the VON's cars, your capital, your offices. They're telling us they're dealing with that right now. The government had already said that it will cover severance pay for the thousands and thousands of people who work for VON and Red Cross and Catholic Charities, so this isn't mythology. They already have plans in the works to swallow you all up.

I have no idea how you're going to survive, because for people who are eligible for long-term care services in the future the purchasing of services from outside agencies is limited by the 80-20 rule. I don't think there would be enough business for the VON outside of the MSA to keep a critical mass to keep the VON going.

Maybe you want to correct me on some of this, but I just don't want people to have misconceptions about this legislation. This is a monopoly. It flies in the face of what we've learned about monopolies in the last 20 years. It's essentially regional government for health care, which flies in the face of our experience with school boards and large bureaucratic organizations. It's exactly the opposite direction to what many of the government's own discussion papers had.

The problem -- and I want to ask you this question -- is, where did the idea come from that the MSA would not only be one-stop shopping? All politicians -- God knows I've only been elected four years, but I was an assistant for many years and used to write speeches for politicians about these things. It was essentially a 1-800 number or something for a local area, and a fairly simple agency would be set up.


That's what I heard during the public consultations on long-term care, but these people came along and put a nice little twist, that they also have to have a monopoly on delivery of services, which, as I read the government's own papers, was never intended until you get to, like, the salmon-coloured one where suddenly or so it's thrown in. Have you heard an outcry from consumers that, first of all, for some reason VON and Red Cross have got to go, and other service agencies, and that they want the government to have a monopoly on the delivery of services? Because we're told very directly that that's what they heard during their public consultations.

Ms McCallum: It's sort of awkward for me to answer that. What we believe should happen is that the communities, through the district health councils, should plan the structures. In that way they can be responsive to the needs of the community and the clients there, and that is the opportunity where the voices of the consumers should be heard.

We attended many of the previous committee hearings and discussions and what not. We hear things perhaps somewhat differently and yet I don't want to criticize what the government has gone through. What we're really saying is that the legislation needs to be flexible enough for the committees within the communities to design them and not a cookie-cutter kind of approach to this being what the MSAs have to be. That's one of the reasons why that four-year time frame is a bit too restrictive.

If the district health councils are empowered and given the resources that they need to properly do community planning, then things will be designed in the way that the community and the consumers need. If all clients or consumers have equal opportunity to be heard, to be involved in the committees, and due process for planning occurs, then it should be in the best interests of the community.

If that means that all service provision is underneath one organization and that organization takes our staff and some of our work with us, so be it. We will alter our structures and our service provision and we will continue. I mean, it's been done in other provinces in a smaller way.

It doesn't necessarily mean the demise, and that's not why we're here. We're not here to protect VON. What we're trying to say is: Consider these things. Let the communities do their planning and let everybody be heard and not any one particular vested interest group drive the process.

One of the criticisms of some of the input that has gone into the government has been from the perspective of the seniors, and it's been well and healthy seniors as opposed to ill seniors. It takes a lot more work to get the ill seniors' voice heard than some of the more organized healthy seniors. That's another aspect of the community planning, to establish it in that way.

Mr Jim Wilson: If I can just add, you did mention other provinces. Manitoba is an example but Manitoba has reversed the monopoly aspect of it because they found it wasn't efficient.

Mr Sutherland: Thank you for your presentation. I guess I had a question. Instead of an MSA, you propose a federated board type of model. On page 7 you talk about your concern about the MSAs, about the bureaucracy which may be inflexible and divert dollars from individuals in need of care to an unnecessarily complex and costly system.

We've heard a lot about the so-called large and, as some have called it, monolithic bureaucracy that an MSA is going to be. You talk about the costs of administration. What if I put forward the argument that the sum of the administrative costs of all of the individual agencies now may be more than what the administrative costs of an MSA are going to be. If that is the case, in the federated board model that you're putting forward where is the administrative streamlining? I didn't quite see that in your presentation, as to where administrative streamlining comes in. You say the boards all work together, but the sense I get is that they're all retaining their separate administrative structures. I don't see where the savings are or the administrative streamlining come from in a federated board model.

Ms McCallum: It wouldn't necessarily. Retaining the individual identities of the organizations and the board structure, the governance structure of individual organizations, the values etc and then a federated board that could have representatives from the different groups, does not necessarily mean that you wouldn't collaborate on an administrative structure. There's no reference to that in there. The governance structures -- those are all volunteers in the organizations that I'm talking about. The board for the VON are all volunteers from the community.

Mr Sutherland: You said you could collaborate on the administrative structure. I guess, then, if you say that is an important part of administrative streamlining and you collaborate on the administrative structure, then what is the difference between a federated board and an MSA if you're collaborating on the administrative structure?

Ms McCallum: The identity.

Mrs Haslam: Actually, the boards are elected in an MSA.

Ms McCallum: Yes, that's one of the pieces of the legislation. They are elected or more formally appointed, as opposed to volunteer.

Choice: When you look at what's in the best interests of the community, if there is no choice for the client or the consumer -- and someone else identified that this morning -- it is a definite concern that we take that choice away.

Mrs Yvonne O'Neill (Ottawa-Rideau): Perhaps you were here for the Lambton women's institute presentation. They talked quite a bit about the district health council and what they expected of it. I found your intervention regarding the Grey-Bruce District Health Council rather interesting. I don't know exactly how this has happened. It's the first one I've heard about that seems to have decided to put MSA governance and its accompanying concerns on the back burner and go another route. I'd like you to say a little more about that, whether everyone on the council agreed to that or how that decision was made. Are you working towards fitting into Bill 173 eventually? At the moment, you seem to be working on other things. At least that's what the brief says.

Ms Kathryn Bamford: Kathy Goetz-Perry, who is the director from the Grey-Bruce branch, is here. She could answer that for you, if you like, if it's possible.

Mrs Catherine Goetz-Perry: My apologies for being late; I wasn't aware we'd been moved forward. In relation to your question, the actions are endorsed by the long-term care advisory committee of the district health council. The intent is to address the service delivery issues of access, integration and coordination first in relation to consumer and stakeholder issues and resolve those problems, those seen as the priority problems, and then address the issues of structure and governance.

Our region happens to be unique in that we only have about seven service providers actually involved in direct home and community support services. In 1992 the Home and Community Support Services Agency was formed as a pilot in Grey and Bruce counties, as you may be aware, to undertake the community and home support segment of services in Grey and Bruce counties. That agency is fairly new in its mandate and is still attempting to address all areas of its mandate.

That leaves a total of four other agencies, including Grey-Bruce Home Care, that are directly in health services. Three of those four are regional in nature. They service all of the Grey and Bruce counties and do satellite service delivery of some type or another. It seemed a natural outcrop of our layout of services in the community to proceed with resolving the issues that came forward as priorities in our community from focus groups held with consumers and stakeholders, those being access and coordination between present providers, and get those issues out of the way first, before we undertake the structure and governance.


Mrs O'Neill: Are you dealing then with some of the frail elderly who have just been mentioned, or are you dealing with just the well consumer?

Mrs Goetz-Perry: We are struggling, as are other regions, in getting the mandate and voice of the frail elderly heard, but in fact the district health council has undertaken direct data information by going out to stakeholders and visiting with clients in conjunction with stakeholders to access those frail elderly consumers.

Mrs O'Neill: I certainly endorse your approach. My final question, do you have a time line?

Mrs Goetz-Perry: In that this project has just been undertaken and that there are workshops set for October 6 and 7, I can address your question at that point.

The Chair: Thank you all again for coming together on a joint presentation. We appreciate what you've done today.

I have two questions that members just want to put, and I go first to Mr Winninger and then to Mr Wilson.

Mr Winninger: I have a question of clarification, and without taking too much time away from the presenters, I wonder if the parliamentary assistant or the ministry officials could indicate what opportunity, if any, there is for organizations such as the VON to maintain their identity once the MSA becomes fully functional.

Mr Paul Wessenger (Simcoe Centre): I'll ask legal counsel.

The Chair: Again, just because of time, if we could be fairly brief.

Ms Gail Czukar: There's nothing in the legislation, of course, that requires VON or any other organization to give up its corporate structure, and so VON and Red Cross and all those organizations can continue as corporations and as non-profit charitable corporations. Whatever activities they carry on outside the publicly funded services that would come within the jurisdiction of the MSA could continue. So they would be able to retain their identity and their structure in the community. Beyond that, it gets a bit complicated.

Mr Jim Wilson: I guess the problem with that, though, is the vast majority of services that a number of these groups are providing are indeed publicly funded. All of those services are being expropriated and put into the MSA.

I want to ask the government, once again, whether it has any studies whatsoever to tell us what the costs of the current administrative structures of the various agencies are now, because Mr Sutherland said it once again in his remarks that the premise of this legislation is that amalgamation will save money. That flies in the face of any amalgamations that we've ever done in this province.

I just went through one in the county of Simcoe where after they amalgamated many of our municipalities, we actually have the first debt in 150 years of over $1 million, because bigger is not better. So I think we are entitled as legislators to know what the benchmark is so that we can measure in the future, through the transition process of MSAs, whether or not there are cost savings when administrative structures are amalgamated.

Has the government to date come up with those figures?

Mr Wessenger: Certainly, if we look at the hospital sector, I'm sure we can provide information that shows, as a result of the combination of administrations, there have been administrative savings in the hospital sector. In fact, we heard in Sault Ste Marie about a saving of $2 million as a result of two hospitals coming together.

Certainly if we look across the spectrum of other areas, we see the efficiencies achieved by streamlining administration. That certainly is a trend we have to continue to do in all sectors, including the sector of the long-term care area.

It's interesting to have heard, for instance, the last presenter, who seemed to have some indication that a federated model, to be efficient, would have to have some common management, some common administration -- in other words, to have achieved those efficiencies -- and who expressed really I think the concern that they really wanted to retain an identity for them more so at the governance level rather than the administrative level. I think that certainly the evidence we've heard, as far as savings, there is a lot of information,

I don't think there are any particular studies in the long-term care area because we haven't had an MSA model up in operation yet, but certainly with respect to the district health council planning process, they are looking at projected costs with respect to the MSA models they are developing and that's part of the whole planning process and that will be submitted to the ministry together with a recommendation of any new model to show the cost savings that may be effected.

Mr Jim Wilson: That's complete bunk and comparing apples to oranges. We have no administrative structures in hospitals in this province that are 100% volunteer as we do in the community-based sector. In many of these agencies -- for example, Meals on Wheels throughout the province in many cases has nobody paid to administer or run those programs; strictly volunteers. In a number of other agencies and in fact the evidence before this committee from almost all of the deputations has been that there will be no cost savings. To compare it to the hospital system, you know, Mr Wessenger, as parliamentary assistant, that many of those savings came outside of the administrative envelope when hospitals have been merged. It's still, I think, incumbent upon you, if you're going to continue to make the statements in this committee that savings will be achieved -- you've got to be able to prove that in fact, prior to the implementation.

The Chair: Final comment from the parliamentary assistant; then we'll have to move on.

Mr Wessenger: I'd just like to point out that certainly with respect to the hospitals, the savings that were achieved, they were proven as a result of the structure; there were no pilot projects in a sense. When you do this restructuring, you have to base it on your best information and your premises. Certainly the district health councils -- I'm sure they're looking at these matters -- can see the savings when you cut down the number of administrators. Your payroll department cutbacks and in the sense your number of chief executive officers is certainly going to make a savings in the administrative area. I can't anticipate how by having less people involved in administration you're going to not have savings.

Mr Jim Wilson: If I may, Mr Chair, the point has been made --

The Chair: I think we have to move on.

Mr Jim Wilson: But in this governance structure, though, which is very often volunteer-based, what about the loss of the volunteers?

Mr Wessenger: Anyway, the county --

The Chair: Order, please. I appreciate the points that are being made. I think the question is on the table.


The Chair: I realize that, Mr Wilson, and I think that's where it is and we have to move on at this point.


The Chair: With us now is the representative from the Belle River and District Community Council. We're glad that you were able to get here and that we can hear your presentation.

Ms Janet St Pierre: Thank you very much. My name is Janet St Pierre. I'm the executive director of Belle River and District Community Council. I will give a brief description of our organization just to give you a clearer understanding of who we are.

Belle River, for those of you who do not know, is located in Essex county just outside of Windsor. It's a small rural community. The Belle River and District Community Council is a non-profit charitable organization concerned with the needs of the residents of the North Shore area of Essex county.

This agency, established in 1985, was organized to plan and organize programs that would meet the long-standing unmet needs of this community. With ever-changing times and an aging population, it was apparent that services needed to be accessed locally. Currently, at one location the residents of the North Shore area can access an information and referral office providing much-needed information to persons of all ages in both French and English. A transportation program, Meals on Wheels, a foot care clinic and a friendly visiting program for seniors and disabled are currently funded by the long-term care office home support programs.

As well, agencies whose main offices are located in other larger cities have placed counsellors on a weekly basis at our location in order to serve the residents in a better manner. These include the Sexual Assault Crisis Centre, Hiatus House, Essex County Social and Family Services, Essex County Crisis Intervention Program, Housing Information Services, and Windsor-Essex Bilingual Legal Services. Access to fax service and telephone is made readily available to VON visiting nurses and public health nurses.

My area of concern speaks to part VI of the proposed Bill 173, on the establishment and designation of a multiservice agency for specified geographic areas. While we realize that changes are about to occur regarding the provision of community support services with the passing of long-term care reform, we need to be assured that linkages within the MSA be clearly defined and that the services that exist in rural areas continue in the same efficient manner that is currently being provided.

Windsor-Essex county is a geographic area encompassing city and county residents with similar yet very different needs. The seniors living in these rural areas depend largely on the friendliness and personal assistance provided to them by their local agency.

I heard people speaking earlier with regard to the importance of volunteers, and volunteers and community support play an important factor in the delivery of these services from small agencies such as ours. I realize that this has been addressed in Bill 173, but again, my concern is that this be a part that's looked at very carefully in the continuation of these services for small rural areas, as our needs are very different than those in the cities.

That is the extent. It's very short, but that is the main concern.

The Chair: Thank you, Ms St Pierre. Just for the record, I note that you've included a copy of the programs and services that are available at the local community information centre, and would note too, just before passing on to questions, that we have had a couple of presenters today who have also put emphasis on the particular needs of rural communities. So while your remarks may have been short, they fit very much in with other things we've heard today.

Mrs O'Neill: If we're putting the program in, I think you can certainly be very proud of the services you've been able to achieve and offer. I guess I have to ask you just where you are in the long-term care planning process. Are you or anyone from your organization involved in the long-term care committee of the district health council? I presume your district health council does include the cities.

Ms St Pierre: Yes, it does. The district health council has been deliberating for a couple of years now in Windsor and Essex county. I myself have not been directly involved on standing committees, although I have been involved in some meetings of other committees. Information hasn't been made available to myself through the committees to make sure that we sort of understand what's happening in our area.

Mrs O'Neill: I guess my question then is, do they understand what's happening in your area?

Ms St Pierre: I don't know. That's one of the concerns, that we don't really know if the cities do really understand the needs of the rural areas within, encompassing, a large multiservice agency that takes care of city and rural people all in one group.

Mrs O'Neill: And you really don't have a defined membership on the district health council then? Is that what you're saying, that the rural --

Ms St Pierre: We have four social planning councils serving the Essex county area, and we do have representation from these social planning councils on the MSA committees. There are voices there, yes.

Mrs O'Neill: Do you get the feeling when you read Bill 173 that it is quite, what should I say, a metro model or a large-city model?

Ms St Pierre: Yes, I do, and that is my concern specifically, that it looks like a large metro model and perhaps these small areas will be forgotten.

Mrs O'Neill: Is it the list of mandatory services that's frightening, or is it the governance structure, or what do you feel could be done to Bill 173 to make sure that rural areas and that the language of "rural areas" are included? Can you not even, if you can't do it today, perhaps follow up to tell us just what parts of the bill and the wording that would help? Because let's face it: There are more rural areas in Ontario than there are urban areas, even though there are concentrations of population.

Ms St Pierre: Well, perhaps there could be wording clearly identifying the needs of the people in the rural areas, or that the rural areas would be looked at and considered within these mandates, within the establishment of the MSAs.

Mrs O'Neill: Perhaps with certain exemptions that may be --

Ms St Pierre: Right.

Mrs O'Neill: Thank you very much for your presentation.

The Chair: Thank you very much for coming from Belle River to the committee this morning.

Members of the committee, I think it's time that we dealt either with our acute short-care needs or our long-care needs and have a break, it having been some three hours since we started, and we do have a very long afternoon.

I have some directions for committee members for lunch, and that is that when you exit this room and you go out and turn to your right, go down the hall to salon A, through the glass doors and then turn right again, and I would assume that either Mr Winninger or Ms Cunningham would be able to find us if we got lost. With those --


The Chair: Order. You see, we're getting frivolous. We need that break. Lunch will be served at 12 sharp, so you have a few minutes to get some fresh air. But I think probably we all need a bit of fresh air, and then we begin again at 1:30 sharp with Cheshire Homes, and just to remind members that we will be going to approximately 6, so I think if people could just kind of revitalize the batteries, that would do us all good.

Mrs O'Neill: Mr Chair, is it possible to have some air in this room? I mean, really, I'm sure that the people aren't coming prepared, with the heat outside today, to sit in this room.

The Chair: We'll look after the heating during the break. With that, the committee stands adjourned until 1:30 this afternoon.

The committee recessed from 1144 to 1332.


The Chair: Our first witnesses this afternoon are representatives from the Cheshire Homes of London. Welcome to the committee.

Ms Mary-Anne Elie: Good afternoon. I'm Mary-Anne Elie. I'm a consumer and a member of the board of directors. With me is Judi Fisher, who is the executive director of Cheshire Homes of London Inc, and Grant Inglis, who is the board president.

The board of directors of Cheshire Homes of London Inc appreciates the opportunity to respond to Bill 173. Our response will focus on comments regarding attendant services and the impact of Bill 173 on those services and on consumer rights and participation.

Cheshire Homes of London Inc is a not-for-profit corporation which was incorporated in 1976 under the Corporations Act with the mandate to assist people with physical disabilities to live independently in the community by providing attendant services and accessible, affordable housing in a manner which enables individual responsibility, participation and integration into community life.

Cheshire Homes currently provides services to 50 people with physical disabilities in the city of London in supportive housing arrangements and to approximately 160 people in the counties of Middlesex, Oxford, Perth, Huron and Elgin through the outreach attendant services program. In addition, we provide 24-hour backup service in the city of London and a respite service in the five-county area. We also have a small respite program for children and work in partnership with the Easter Seal Society to provide respite for children at Woodeden Camp outside of London. There are currently 122 people waiting for attendant services in the five-county area.

The attendant services provided through Cheshire Homes of London are funded 100% by the long-term care division of the Ministry of Health. Housing arrangements are funded by either Canada Mortgage and Housing Corp or by the provincial Ministry of Housing. All housing has a rent-geared-to-income component.

Bill 173, part II, interpretation, page 6, sections 3, 4 and 5, list of services: We feel it is critical that the list of services provided in this legislation is comprehensive and that the description of the services is clear. It appears that some services are offered in more than one category, for example, meal services and preparing meals. Currently, these are services provided under attendant services. Will consumers now have to access meal preparation elsewhere and will these services then be subject to a fee for service? These are very important questions for people who cannot survive without these essential services.

Attendant services: There is no mention of attendant services in the legislation nor is there any guarantee in the legislation that attendant services will be offered other than in the multiservice agencies. Consumers in Ontario who use attendant services have fought hard to have the distinction of attendant services from other personal support services recognized. This distinction has been recognized in the new training program for workers which has two categories -- personal support worker and personal attendant -- and in the work that was done with the Regulated Health Professions Act. There have also been guarantees made to people with physical disabilities in Ontario that they will have a choice of where to receive attendant services.

The compendium to the Long-Term Care Act distributed by the Minister of Health on June 6, 1994, states on page 19:

"Distinct personal support-attendant care services:

"In keeping with commitments made to consumers with physical disabilities, some communities may choose to retain...attendant care programs, with access managed and services arranged by the particular service provider. Communities will determine how their attendant care services are to be organized through the local community planning process. Every MSA nevertheless will provide personal support/attendant care type services for consumers who wish to access these services through the MSA."

Consumers feel that if the distinction is not stated in the legislation it will ultimately be lost.

Our recommendation: We recommend that the list of mandatory services be well-defined in the legislation. We further recommend that the attendant services be specifically referred to in the legislation and that reference be made to the choice of having attendant services accessed outside of the MSA if that is the wish of consumers in a specific community.

Part III, bill of rights, page 7: We are very pleased to see this very important protection for people who use community-based services included in this legislation. We did not, however, see any specific reference in the legislation that said an approved agency must comply with the bill of rights.

Our recommendation: that part V, page 10, subsection 7(1) be amended to include compliance with the bill of rights.

Part IV, multiservice agencies, subsection 11(2), board composition, page 11: Our concern with this section of the legislation is that there is no specific mention of consumer participation on the boards of directors of the multiservice agencies. We feel it is imperative that people who use the services should be represented on the board of directors which governs the services.


Our recommendation: that Part VI, subsection 11(2) be amended to include people who use the services through the multiservice agencies.

Part VII, rules governing approved agencies, waiting lists, page 16, subsection 20(2): We feel that this section of the legislation which refers to waiting lists needs to be expanded. There are currently 122 people waiting for attendant services with Cheshire London, over 50 people in the city of London alone waiting for the outreach program. Some of these people have been waiting since 1987. Many people who are waiting for attendant services are using services that are more costly; for example, they are institutionalized or they are using professional services such as nursing.

These services are not only more costly but totally inappropriate and people who want to get on with their lives are forced to play the waiting game. There is no systematic mechanism for monitoring these waiting lists.

Our recommendation: that subsection 20(2) be amended to include a comment about a review and the monitoring process.

Quality management, page 17, section 24: We are pleased to see that the assurance of a quality management system has been included in this legislation, but feel that this section has left too much for the regulations. We question whether process is a more appropriate term than system. Process by definition is ongoing. We feel that the legislation should be more specific with regard to the criteria to be met with quality management.

We also feel the legislation should state that consumers who use the services must be involved in this process and that the information should be made available to the consumers and to the public.

Our recommendation: that section 24, quality management, be expanded to include some criteria for evaluation and reference to the inclusion of consumers in the quality management process and reference to the information being made available to the public.

In summary, the board of directors of Cheshire London is confident that Bill 173 will enhance community-based services and will strengthen protection of rights for people with physical disabilities in Ontario. We hope you will consider our comments as constructive criticism only and we wish you luck as you work towards third reading of this legislation.

The Chair: Thank you. I think all committees appreciate your last point as we proceed to deal with the legislation. We'll go to questions.

Mrs Cunningham: Thank you very much. This is one of the agencies I think, Mr Chairman, that we're very proud of in the city of London for the work that they do. They've been very, very vocal, at least as long as I've been involved, in letting us know what we do well and what we should do a lot better.

I think the waiting lists speak for themselves when we're talking about health dollars: the kind of money that we spend on health care; the fact that we now know this number is 1987 and, until two months ago, I think we could probably have said 1984, in that one of the people waited a decade to get out of an institution, to be in their own place with their friends and family. So we have a lot to be accountable for.

Thank you very much for being so specific with regard to your recommendations. I wanted you to know that with regard to the mandatory services and with regard to attendant services, we have amendments that we will be putting forward to most of the issues, I think, that came forward today. They're written and we're ready to go. We've certainly heard some of the things that you've stated across the province for at least the last couple of weeks and longer and so we've acted on them.

I wanted to ask you how helpful you think this act will be to some of the challenges that you are facing within your own agency. Where will it be the most helpful, if at all?

Ms Judi Fisher: That's a good question, Dianne.

Mrs Cunningham: We spend a lot of money doing this, you know, rewriting stuff and paying lawyers and all the rest and I often wonder why, so I'm just asking you.

Mr Jim Wilson: We didn't; the government did.

Ms Fisher: Do you want me to answer?

Mrs Cunningham: What's helpful and what isn't?

Ms Fisher: Yes, I think it solidifies the community-based services and gives sanction to much of the work we've been doing. Certainly, there's sanction in the legislation with public hospitals and that sort of thing, where our services in the past have really been a very small reference in the MCSS act and so I think it gives more distinction. In terms of the bill of rights for consumers and the appeal process, it certainly gives consumers a lot to act on that is legislation, so therefore is law. No, I think it's a very, very important piece of legislation for us.

Mrs Cunningham: Could I ask you with regard to the expectations, because when you list the services that are being available, and I know one of your recommendations is to add to that list or to make it more clear -- by raising these expectations, I'm assuming you're thinking that we're going to save the money Mr Wessenger talked about today, so we can provide services and not have waiting lists. Do you think that's one of the expectations of the public in this regard?

Ms Fisher: That will save money?

Mrs Cunningham: The waiting lists have been one of the great concerns that we've all heard about. As people come forward, we have to ask ourselves how can we be spending this kind of money per day in an institution, when it's so much less expensive to have someone in their own home?

Ms Fisher: I think probably there are a lot of people who have answered those questions long before I ever came on the scene. Robert Sutherland probably gave one of the best answers when he said the only way we're going to actually save money is if we close the beds and transfer the dollars. I certainly commend this particular government for doing that. The only way we are going to save the money for the people who are on waiting lists in institutions is probably that we somehow close some of the beds and move the dollars. I certainly feel the political will is there to do that.

Mrs Cunningham: Is the waiting list for beds longer now, in the last two or three years, in your agency?

Ms Fisher: We've consistently had long waiting lists and it fluctuates. I've been with Cheshire London since 1981 and when I first came I think maybe the waiting list may have been 50 and then there've been periods where it's maybe been a couple of hundred and we've been fortunate to get some expansion dollars. There are probably as many people waiting for the services as currently receive the service in almost every area of the province, I think.

Mrs Cunningham: And just the last question, Mr Chairman: With regard to section 23, quality management, wouldn't one of the criteria for evaluation be -- at least with your agency -- waiting lists?

Ms Fisher: Yes.

Mrs Cunningham: If we pass this, if this goes into effect, wouldn't it be a fair question a year from now? I've been around a long time and waiting lists are growing, in spite of all of the legislation. So if I don't sound particularly positive, I think it's because if something isn't working, fix it; don't write more books. I'm just saying, would that be a fair criterion: You should have less waiting lists for homes and for care givers?


Ms Elie: Absolutely. I can only speak to this from a personal point of view. Without a place like Cheshire Home and the services they can provide -- I'm not sick. However, I'm not going to get better. But I don't need a hospital bed. Having a hospital bed and having nurses and doctors around me all the time isn't going to make me get better. I just need some physical assistance to be able to run my everyday life: to get up and go to bed and shower and all those kinds of things. Without places like Cheshire Home that can offer services like that, personal support services, I am looking at spending an awful lot of the rest of my life in a hospital, and there are an awful lot of other people facing the same thing. So we really need things like this, personal support, attendant services, things like that.

The Chair: Thank you very much. I would note, long before I got into this business I remember being at the opening of the first Cheshire Home here in London, and I'll pay tribute to my cousin, Nancy Skinner, whom I'm sure you know, both as a consumer of services as well as somebody who's been very active in working on these issues. So I've felt that I've lived with Cheshire Homes and all that you've done. So, as always, it's a pleasure to have you before the committee and to commend you for the tremendous work that you do, and we thank you for your presentation today.


The Chair: If I could then ask for our next presenter, Participation House Support Services from London and area, if they would be good enough to come forward. We welcome you all to the committee, and once you're settled, please introduce yourselves and go ahead with your presentation.

Ms Elizabeth Leighton: Thank you very much for inviting us here today. My name is Elizabeth Leighton. I'm president of the board of directors of Participation House Support Services of London and area. On my immediate right is our executive director, Brian Dunne; on my left, Carmell Tait, who is the director of support services for our agency. We've presented to you our paper, and you can see by the question that is the title of the paper our concern, perhaps, in a nutshell. Additionally, we have in the first numbers of pages an executive summary, and we'll leave that with you to read at your leisure, as it simply summarizes the paper.

To introduce ourselves to you as well, we've presented you with a booklet that we have called Participating, Involved, Included and In Charge: Individually Designed Supports, which indicates our philosophy as Participation House and what we hope to do within our community.

We are a community-based and non-profit service agency. We were started in 1980 by parents of adult children who had physical disabilities and often some other disability as well, in fact were started with many bingos and continued in that vein until we were funded as an agency by the Ministry of Community and Social Services in 1988.

These parents and their adult children created this service because the attendant services and other existing community services could not and were not designed to meet their needs. The people required additional support and guidance that was not available to them in the community, and certainly "in the community" is stressed. That is where those people wanted to live. However, they needed more than mere visitation or any kind of on-call services, and today our agency supports these people, who have such disabilities as very severe cerebral palsy, multiple sclerosis, other physical disabilities and often a combination of disabilities. We currently support 32 people under the long-term care ministry. Additionally, we have nine individuals under the Ministry of Community and Social Services. These people are supported in homes and have 24-hour-a-day support, which is absolutely necessary for them to remain in the community, where they want to be.

Our guidelines and our legislative basis for service and funding originally came under two acts, and you'll see that noted in our paper, the Homes for Retarded Persons Act and the Developmental Services Act. However, in 1992 the existing programs were moved to the long-term care division, and in fact currently we are still unclear as to what legislation we operate under. Bill 173 doesn't seem to do anything to help us set the matter straight, and in fact that is because our perception of this bill is that persons with these great needs seem to have been left out of the bill.

The continuing lack of clarity, the fact that after two years no one within the Ministry of Health appears to be able to tell us exactly where we as an agency and a support service fit in, nor have officials taken time to make that determination, explains why the people we support and their families and those on our long waiting list have felt excluded from long-term care reform. Last night you heard from Deborah Jazey, on the Waiting With Concern Committee. She is the chair of that committee, and they represent that kind of feeling of exclusion. The vulnerability for persons with great disabilities seems to have increased. Their needs have been ignored.

It appears to us that there has of course been a philosophy of deinstitutionalization and community living. However, it appears to be misunderstood, and particularly with regard to the concept that this is for all persons no matter what and how severe their disability. It is inferred that those with high care needs have no guarantees, nor the right to live in the community, as their "dollar could be used to support so many others," and we've put that in quotes as that is a quote that we've heard many times. The concept of basic entitlements for all and equity in having basic needs met, in our practical experience with long-term care, has been replaced by concepts of, again I quote, "bang for the buck." Bill 173 and the long-term care reform lacks a clear commitment to all individuals with disabilities in the community. It fails to guarantee concrete services and functional support.

For our paper, we wanted to look at how this bill had things to offer to the people that we support. We wanted to look at what perhaps has been simply forgotten in the bill and what our overall impression of this bill is and the impact on the community.

Therefore, we've looked at the seven stated goals of the bill and we're going to give our opinion as to whether or not we feel those goals can be achieved for the individuals that we support, those individuals with severe and multiple disabilities who require 24-hour-a-day care. These are the people that we deal with.

Goals 1 and 2 you'll see at the top of page 7, and all of these goals quite frankly seem to be goals we would like to see have a final achievement, certainly as far as the persons that we are dealing with. However, the goal to provide a wide range of community alternatives to institutional care and to improve community services falls short with regard to our people, because we see the bill as being silent regarding the fate of people who are very difficult to serve. It does not guarantee that all people will have their basic needs met within the community regardless of their level of disability. People that we support were last in line to receive service before, and now we wonder whether or not they'll even get into the line, under this bill. More and more services are being moved to the community. However, there appear to be fewer and fewer guarantees being made.


When you look at community service, you realize that it doesn't seem to ever have had the power or prestige that entitlement and guarantees have had. Greater numbers of people are being pushed into an uncertain position; those most vulnerable are most likely to lose. Our reading of this bill is that it clearly lacks the philosophical commitment and teeth to ensure people who have high levels of disabilities will get their needs met and experience quality of life, again underlined, in the community.

The bill also continues the waiting list placebo. I was listening to Dianne Cunningham's comments. It appears that you're all aware of the waiting list problem. This problem has gone on in the community for years, and our reading of this bill is that this issue is not addressed. Service providers, families and consumers attempt to plan for their future. That planning is impossible, given that only ministry funding decides on movement on a waiting list. If the bill, as we read it, doesn't guarantee service or movement, those people are going to continue waiting and be unable to plan for their future.

The artificial limit that only 20% of services can be purchased from other services by MSAs ignores the needs that individuals may have. It's an artificially created number. It doesn't seem to have a rationale in consumer need.

Finally, the bill has ignored the most important questions, again leaving people that we serve in limbo, those questions being: What are the basic needs that will be provided for in the community? Additionally, is there a cutoff point or a maximum that will appear in the regulations after this bill has been passed? Are those we support allowed in the line, or is it possible that they will lose their community service?

Those who are in the community and who brought dollars with them from the Ministry of Community and Social Services do not appear to be guaranteed continued support in the community by this bill. You cannot leave entitlements and maximum amounts of service to be determined by officials and bureaucrats within the Ministry of Health. This should be clarified before the final reading of the bill.

The next goal is to recognize the importance of a person's needs and preferences in management and delivery, again an excellent goal. We commend you for looking at consumers' rights within service.

However, we question why the choice of service provider has been limited by the creation of MSAs and a 20% limit for purchase outside the MSA has been chosen. We wonder why the concept of individualized funding was not looked at. If you can change the service, why can't the individual pick the provider?

The cost and quality would come quickly into place if the consumer was able to dictate the expenditure of his or her dollars. This would be less costly and ensure quality far more effectively than the cumbersome review and appeal process and the quality assurance outlined in Bill 173. The bill does not clearly define the objectives, methods, jurisdiction or enforcement procedures of quality assurance.

Goal 4, the creation of these MSAs: We wonder what the intent of this change is. There appears to be nothing in place within the legislation to ensure that the amalgamation of service must be or is directly tied to more dollars going to front-line and direct support to an individual consumer, nor does the bill imply that those services that spend the largest percentage of government dollars on direct care will lead the process. It appears that lost is the intent of saving dollars for consumers' use. The legislation does not appear to ensure that when all is said and done, there must be clear results from the amalgamation. Of course, we're all very much realizing that in this day and age we're looking for improved services for many more individuals, using the taxpayer's dollar, and it is the taxpayer who is questioning more and more how those services are being provided, how that dollar is being used.

Goal 5, improved and consistent accountability regarding equitable access, rules and procedures: Again, back to the taxpayer, who is saying, "Who's accountable for the use of my tax dollar?"

We feel that this bill has not addressed the question of equitable disbursement of finite dollars to those people with needs and disabilities within the community and how that will occur. This cannot be left to be defined out of the public eye and within the bureaucratic system. This goes to the question of entitlement and guarantees for all.

Moving greater numbers of people -- and we've indicated seniors, acute home care, people with AIDS -- away from the protection of the Canada Health Act will leave the most vulnerable and least vocal within the community, and those are the people that we support, at the bottom again, pushed farther back in line for community service. How is the bill accountable to these individuals? What guarantees are they given? We do not see how the stated goal of equitable access translates into equitable service provision.

So goal 6, which is again accountability, we feel is not clearly outlined in the bill with regard to the lines of accountability. The diversion to provincially appointed community councils which lack clear local decision-making power and concrete community support is perhaps just an illusion being created to keep the ministry from being held accountable. There seems to be a blur of consultations and an infinite number of committees and subcommittees of the council. You heard from Deborah Jazey last night her committee's feelings of being simply put off from one committee to another committee. It appears that all the efforts of these innumerable committees simply deflect energy that might well have been used to reform and improve the service to the individuals. Is this bill simply distracting the attention away from the people who are in need?

Goal 7, then, the local planning through the district health councils: These are councils, of course, that were already in existence and have now been given an enormous task, and we question whether or not that task will make them simply another confusing layer within the reform process.

Additionally, this is an appointed body, and we wonder if indeed it will represent its community. How will it be accountable to the local community? We have some local planning. However, there does not appear to be a right or power or any kind of local membership. An appointed consumer representative does not necessarily represent or is not necessarily the choice of the consumer. Indeed, practice has shown that a number of persons who belong to long-term care committees under a category that is called "other" are in fact a disproportionately large number of service providers, a category on the committee that is already there.

We are service providers, and we have become totally confused as to how the ministry office, district health council and MSA will interact functionally. We feel that the bill should attempt to clarify that. Our perception of the bill as it reads now is that it's a proposed reform that leaves us still in a state of confusion and chaos and stagnation.

In closing, of course, as I indicated before, the goals are admirable and we underline them. Unfortunately, little within this legislation seems to be specifically defined to provide us with a sense that the drafters of the legislation have had a clear idea of how to achieve the goals or have a clear commitment to those goals.


What is the real intent of this legislation regarding specifically those people we serve, people with great disabilities? By refusing to define clearly and precisely entitlement, equity of service provision, basic needs guarantees, those people we support and those who wish our support continue to be left vulnerable and in fact with a feeling that they are unsupported within the community. Thank you very much.

The Chair: Thank you for your presentation. I know that the parliamentary assistant wanted to comment on a couple of the points for clarification.

Mr Wessenger: I think I'm going to ask ministry staff to explain how your organization fits under this bill so that it will be clarified.

Mr Geoff Quirt: As you pointed out, the government's responsibility for funding your program did shift from the Ministry of Community and Social Services to the Ministry of Health. There were a number of programs that served people who were labelled as both developmentally handicapped and physically disabled, where there were discussions about whether it was most appropriate for Comsoc to continue to fund those programs along with its other programs for developmentally handicapped people or whether it would be better for your program to be considered among those that serve people with physical disabilities.

You are funded under the Ministry of Health Act. You used to be funded under the Ministry of Community and Social Service Act. Neither act says anything about disabled people or developmentally handicapped people. This will be the first time that there has been a piece of legislation that addresses community services for the people you serve.

It's not our intention to take your money away. We're almost doubling the amount of money that we're spending on supportive housing programs like the one you operate and we hope there'll be a much more flexible and increased approach to attendant care services. But, as you pointed out, we're not going to eliminate the waiting lists. We hope we'll have an impact on reducing them by providing more service than we do now.

Ms Leighton: I'm going to take under advisement what you've said, especially those last few words. Thank you very much, and I hope that we'll see that sooner rather than later.

Mrs Haslam: I want to mention accountability, because accountability is one of the things that I think the consumers really want. They want to have a local board, and when you talk about the district health council not being reflective and appointed boards and things like that, I'd like to point out that the reason we're putting in place elected boards at a multiservice agency is so that consumers can have access to and input into the decisions around what kind of an MSA they're going to have, and the accountability for them is there not only in the bill of rights but in their input into that MSA board. I would assume that you would be very interested in being part of that process, in putting in place that board for a multiservice agency.

Ms Leighton: We would, of course. I think the point we were trying to make was that with appointed members, specifically of the district health councils -- and of course our position is, and I think it's the position of most taxpayers in Ontario, that the dollars that are taxpayer dollars should be used most wisely and should be used to give the consumer as much as possible what the consumer is looking for. Our concern is of course that the consumer does not seem to have been included in these district health council appointments and that perhaps with another method, of the district health council perhaps being elected, the consumer at least would have a vote there.

Mrs Haslam: We have a brand-new district health council. We were the first ones to look at it and the last ones to get it in the province. I see a good input from all of the community into that district health council and I see that council working very closely through subcommittees, through volunteers, through long-term care committees, with many people in the community to put together that planning. If that's not the case in your area, then I think maybe that's something you can address here.

Ms Leighton: I don't think we're really pointing the finger at an area at all. What we're doing here, at least from my perspective, would be to look at this legislation from a taxpayer's point of view and to wonder if in fact the taxpayer generally, not necessarily the consumer himself, can say, "I have had input into this, I have voted for this and if things go wrong I can change this." I think that more and more taxpayers are wanting to do that as they become more and more perhaps critical of how their dollars are being used.

Mrs Haslam: Can I ask for clarification on that one?

The Chair: Quickly, please.

Mrs Haslam: Are you making a difference between taxpayer and the consumer of the service? Are you saying taxpayers should have more input than the consumers? Are you making a distinction between those two?

Ms Leighton: No, not at all.

Mrs Haslam: It sounds like you are.

The Chair: I'm sorry. We have a full afternoon and every now and then I have to play the heavy. We appreciate very much your coming before the committee and for your presentation and wish you the very best in all your good works.

Mrs Haslam: In between, I'd like a clarification also from the ministry. In the previous presentation from Cheshire Homes, I was unclear about what something in their document was and that was on page 3. They said that there was no "specific reference in the legislation that said that an approved agency must comply with the bill of rights." I'd like a clarification on that because I believe that the bill of rights does cover that approved agency. Could I have clarification on that?

Mr Quirt: It's my understanding that the bill of rights applies to service providers in the act, which would include both approved agencies and multiservice agencies.


The Chair: Welcome to the committee. When you're ready, please go ahead, and also introduce yourselves for Hansard.

Ms Dana Howe: I'd like to introduce us. On my right is Mrs Peggy Davis. She is our director of special services with the social services department and she's also a member of the long-term care committee of the district health council locally. I'm the commissioner of social services with the city and I'm also on the implementation committee of the hospital reconfiguration in Windsor.

We're very happy to have the opportunity to be here today. We have indeed used almost every opportunity to petition the government on this issue that we feel is very important and lacking in the long-term care legislation and in other legislation. To start off with, we'd like to commend the government for its recent actions, through this bill and other related legislation, in recognizing the unique needs of long-term care consumers.

Bill 120, the Residents' Rights Act, which established retirement homes, hostels, rest homes, lodging homes etc as care homes, should do much to manage the tenancy and housing issues. However, the care component remains to be addressed. Likewise, while Bill 173 establishes the policy framework for community-based long-term care services, the legislation is also silent in respect to the needs of individuals who reside in care homes, which aids to perpetuate existing gaps in service provision.

With the enactment of the long-term care legislation, the opportunity now exists to confirm and ensure appropriate service provisions for the residents of care homes who are among the most vulnerable in our communities. If the vulnerability of these residents is to be recognized and if vulnerable adults in the province are to receive the protection necessary to their enjoyment of the same rights and quality of life as other citizens, further steps must be taken to ensure their safety and wellbeing. The basic fact remains that should a resident of a care home have a concern over the care provided, there is nowhere to turn, there is no one to call, write to, no provincial authority designated to ensure accountability or otherwise.


In August 1992, Windsor city council endorsed a submission to the Commission of Inquiry into Unregulated Residential Accommodation outlining 19 specific recommendations which we have included as an appendix. Among those recommendations, however, we highlight:

(1) That the province should assume responsibility for regulation;

(2) That the province effect regulation through amendment of existing legislation, ie, the Ontario Building Code, the Homes for Special Care Act and the Landlord and Tenant Act;

(3) That the province establish an adult protective services program;

(4) That the care operators be required to enter into individual lease agreements with the residents on an annual basis;

(5) That the province recognize the empowerment of the individual as primary in the development of regulation; and

(6) That the province initiate a pilot program within a community where there exists an effective municipal bylaw regulating care homes.

Further to the release of the commission's report, A Community of Interests, Windsor city council, in September 1992, unanimously endorsed Dr Lightman's 144 recommendations, including the recommendation that Windsor be considered as a site for any comprehensive community care pilot program. This resolution was communicated to the ministers of Citizenship, Community and Social Services, Health and Housing.

In response, the Minister of Community and Social Services advised council of the government's intention to review the recommendations of the commission while establishing an interministerial committee to assess the recommendations. The Ministry of Community and Social Services then engaged Ernst and Young to conduct a domiciliary and emergency hostel review, the final report of which was released in November 1992. Further to this review, a project to reform the GWA, general welfare assistance hostel system, has been announced, in which this municipality has been invited to participate.

The most recent government initiative has been the enactment of the Bill 120, the Residents' Rights Act, 1991. The legislation confirms the mechanism to manage tenancy issues wherein the landlord of a care home must meet established provincial guidelines which protect residency. There is, however, no such legislative commitment regarding expectations or standards relating to care.

Outstanding issues. Our present concerns in respect to what has been accomplished to date relate to three areas:

(1) The failure of the domiciliary and emergency hostel review to create an accurate picture of domiciliary hostel residents and the current state of services available to them;

(2) The failure of the government to date to seize the initiative presented within the Lightman report, particularly in respect of support and protective services for vulnerable adults in care homes;

(3) The increased vulnerability of care home residents as a result of the failure of the current long-term care reform process to include care homes within the long-term care strategy.

(1) The hostel review. A major and fundamental flaw within the recent and prior reports concerning care homes is the failure to separate domiciliary and emergency hostel residents in both their quantitative and qualitative research. As a result, the service-intensive emergency hostel system has distorted the service picture of domiciliary hostels in general by suggesting more services than actually are provided.

The research was equally flawed in its failure to elicit adequate consumer input. For example, in one major report, seven residents from a single domiciliary hostel constituted consumer input for the whole province, yet the report proceeded to make assumptions in respect to quality of service based on this totally inadequate consumer sampling.

Various reports repeatedly state the lack of recognition by the province of the key role of care homes in delivering extensive services as a primary issue, and that as a result, the per diem is inadequate. This statement is founded on the assumption that operators should be in the business of providing services.

It is our position that care home residents are a growing part of the community and should therefore have access to generic long-term care services, just as any other citizen. The Lightman report illustrates very clearly the inherent conflict between the profit motive and any inclination an operator may have to provide adequate support services.

In terms of funding, prior reports basically suggest giving more money to operators by way of purchase-of-service contracts with municipalities in exchange for provision of a specific package of services. No specific accountability measures are proposed other than a general statement that new mechanisms should be designed to monitor the effectiveness of the programs.

Our extensive experience in administering purchase-of-service agreements with care homes and in a setting regulated by a comprehensive municipal bylaw has shown us that direct enforcement of standards aid to ensure the delivery of adequate service. However, it is our position that apart from the provision of board and lodging, wherever possible, services should be handled by community agents other than the care home operators. Only then can integrity of the support services to vulnerable adults in care homes be protected.

Further, a conflict exists in respect of the administration of residents' personal needs allowances by care home operators. Recent changes to family benefits legislation have facilitated the payment of personal need allowances directly to the operators, as opposed to the residents. Windsor city council has recently petitioned the Minister of Community and Social Services to take action to redress the problematic situation. For its part, the Windsor department of social services has intervened to ensure that the direct delivery of personal needs allowance cheques to subsidized residents. However, there is nothing in place to protect the interests of private paying residents or care residents on a provincial scale.

Private paying residents are required to purchase additional costly services or service packages which may far exceed their needs, whereas the other community residents are able to access individual assessments as well as direct service provision from a community agency which operates under provincial regulation.

(2) Complementary legislation and support. The action of the government in expanding the Landlord and Tenant Act, the Rent Control Act and the Rental Housing Protection Act to cover care homes is consistent with the recommendations of the Lightman report in that it thereby recognizes care homes as residential, as opposed to institutional, facilities. With Bill 120, the government has taken a positive step in this direction. What should follow, however, is the expansion of other pieces of existing legislation so as to ensure the safety and well-being of the residents, ie, the Ontario Building Code, the Ontario Fire Code, the Planning Act and the Health Protection and Promotion Act.

The government is to be lauded for ongoing action undertaken over the last two years in respect of the development of the Advocacy Act, the Consent to Treatment Act, and the Substitute Decisions Act. It is our position that further action must be taken in respect of the creation of protective services for vulnerable adults. The Lightman report has proposed a bill of rights, a rest homes tribunal and the mandatory reporting of abuse of vulnerable adults. In its submission to the commission of inquiry, Windsor city council went even further in proposing an adult protective services program.

(3) Long-term care reform. We do not ignore the fact that care home residents, as vulnerable adults, are medically frail or at risk by definition. It is essential therefore that all community health services be readily available to them as they are to other citizens who live at home. It would be essential that the single-access system under long-term care reform include care home residents.

We are dismayed, however, by the fact that the long-term care reform legislation to date has consistently excluded care home residents from their target group. We have been told that the needs of vulnerable adults in care homes are to be addressed by the government action in respect to the Lightman report. However, action to date, ie, Bill 120, can in no way compensate for the exclusion of care home residents from long-term care reform.

The virtual shelving of the medically at risk care home population in respect to any discussion of long-term care reform has been running parallel to increased efforts by hospital discharge planners to release long-term care facility-eligible individuals to care homes. Cutbacks in hospital budgets and bed closures are therefore compounding the problems associated with the frail elderly in care homes. The results of these policies and practices are increased serious occurrences, including accidental deaths, as a result of inappropriate placement of heavy care individuals in care homes.

As appropriately classified by the government, through expansion of the Landlord and Tenant Act and the Rent Control Act, care homes are residential, not health care facilities. All too often, in an attempt to control resident care, operators resort to inappropriate practice: for example, locked floors and utilization of physical and chemical restraints. Accordingly, heavy care individuals should have no place in care homes, yet our experience has proven otherwise, as demonstrated by continuous serious occurrence reports involving falls, medication errors, injuries, wanderings and other mishaps involving the frail elderly in care homes. While the Windsor bylaw regulates against admission of heavy care individuals into care homes, it is the operator's obligation to maintain appropriate admission standards. Regardless of this fact, it is our experience that operators accept inappropriate referrals.

As stated, hospital budget cutbacks and bed closures are compounding the problem, along with the fact that many areas of the province, including the city of Windsor, are underallocated in respect to approved long-term care facility beds. While placement coordination services maintain total responsibility for placement in a long-term care facility, care homes are underregulated and open to abuse. The reality of the situation is that individuals are being warehoused in care homes, pending appropriate placement which may or may not materialize in time, resulting in the operation of bootleg nursing homes under the guise of care homes, totally condoned by the province.

In the early 1970s, the province began the depopulation of psychiatric facilities without appropriate community supports in place. Further depopulation is intended, and it is inexcusable to allow the same fiasco to occur by conscientiously excluding care homes from the long-term care continuum. From a municipal perspective, this is not only an abuse of our partnership; it results in the provincial downloading of responsibility for health care at municipal taxpayer expense.

Conclusion. While we recognize and applaud the government's recent initiatives as demonstrated by the advent of Bills 120 and 173, we strongly urge that further actions are required as follows:

(1) The placement of care homes under the umbrella of all other pertinent existing legislation in order to ensure the safety and wellbeing of all vulnerable residents;

(2) In the context of both the general welfare assistance hostel review and the long-term care reform, that the government ensure the separation of services from board and lodging in care homes, and further, that the delivery of services be under the auspices of long-term care legislation;

(3) That the province recognize the existence of the vulnerable adult population in Ontario and move to empower this group through the establishment of a proactive adult protective services program. This program will include provision to protect the personal and financial interests of vulnerable adults, which includes care home residents;


(4) That the government enforce those provisions available under the Nursing Homes Act which prohibit the operation of an unlicensed long-term care facility or bootleg nursing home.

The Chair: Thank you. You got a tremendous amount into the time slot. We appreciate that, because you've also touched on some points which I don't think have come up as directly. We'll move to questioning.

Mr Ron Eddy (Brant-Haldimand): Thank you very much for your very effective presentation on behalf of individuals in care homes. This is a battle that's been waged by municipalities for many decades. I appreciate the detail that you've included and the recommendations or the conclusions that you've arrived at, because it does need consideration and should certainly be included, in my opinion. I certainly share with you the concern about the warehousing of individuals in inappropriate situations with all the problems, having been a member of a social services committee.

You have conclusions here and you stress those. You strongly urge that these actions, as required, be followed. I really have a question to the ministry, to respond to that, but I'd ask you to further elaborate on your conclusions, if you would.

Ms Howe: In terms of suggesting that care homes come under the umbrella of all pertinent existing legislation, if we just use for example the long-term care legislation, by the mere fact that care homes are not included in the continuum of long-term care, then the services that go along with long-term care are excluded from that population.

For example, where you may have placement coordination services looking at and assessing a client or a patient's needs and then determining what level of care they require, then they go into a system whereby they are slotted into the service that best meets their needs. In this situation what happens is, discharge planners don't have to go through the process of placement coordination, and they go out to for-profit homes in the community and they say, "We have someone for you."

These homes in the community are not nursing homes. They are regulated by a local, small bylaw that we're trying to do a very big job with. They don't have nurses on staff, they don't have proper staff-to-client ratios, and they have some of the most needy clients being placed through the back door. In addition to that, we have even found some discharge planners and operators going to the point where they're telling the family: "Don't go to social services. You're going to have to pay this yourself because they won't let you put that person in there."

It's a way to exclude us from the loop, because we don't have authority over the private-paying people in the same facilities, and we have had, in a one-month period in one home, two deaths where people have fallen from balconies, both private-paying residents.

So that's why we're very, very strong on the fact that the whole care continuum has to incorporate what have been traditionally called rest homes, lodging homes, hospitals or whatever, now called care homes. That's a really interesting terminology, the fact that the government has now called them care homes, without including them in the long-term care continuum. I think that's quite an anomaly.

Mr Eddy: Thank you very much for being so specific. It's important. Mr Chair, I would request the parliamentary assistant to respond. Is this being looked at? It should be. Is it?

Mr Wessenger: I am going to ask the ministry staff to elaborate on some of the issues raised. I don't have an expert here on Bill 120, but I understand it does give the ability of the resident to decline the services component of the package. So that is, I believe, in effect.

I certainly think long-term care services would be available to residents of care homes under this bill, but perhaps what you're referring to is more of a residential care package.

The Chair: Mr Quirt, and then, Ms Howe, we can continue that once he's finished.

Mr Quirt: I'll try to respond as quickly as I can. People who live in unregulated rest and retirement homes are eligible for services from the MSA if those services aren't already part of the package of services they've purchased. So, for example, if you lived in a rest and retirement home and had your room cleaned and your bed made and your meals provided, you'd be eligible for things like a visiting nurse or a visiting therapist, but you wouldn't be eligible for a visiting homemaker because you've already paid for that type of service in your living situation. So those clients are eligible who do receive home care services now and they'd continue to receive those professional services.

With respect to Bill 120, you're quite right that the measures taken to date by the government provincially have not included the inspection and monitoring of private sector rest and retirement homes, the care provided there. The government's approach was one of providing consumer protection to the people purchasing those services in the private sector by extending the provisions of housing protection to them. Mr Lightman's report, as I recall, recommended kind of a consumer protection approach on the care side of it. But you're right, there was no move to monitor and inspect the care provided at either the municipal or provincial levels.

The only other point I'd mention in response to your recommendations is that the Nursing Homes Act currently prohibits someone from misrepresenting a rest and retirement home, using the term "extended care nursing home" and implying to the public that it's a publicly funded and licensed facility. But you're not breaking the law by offering similar kinds of services in a private residential facility that are publicly funded in a nursing home.

Ms Howe: Just in terms of the last remark first, I think this probably is one area that is tremendously misunderstood by the public. They don't really understand, and sometimes I don't think that doctors really understand what the difference is between the different levels of homes and what they provide. As a result of that, the public can be lulled into complacency by thinking that their loved ones are being placed in a facility where monitoring is going on and in fact it's not. I hear what you're saying, but I think in reality there's a major problem out there.

Mr Quirt: I think you've made a good point about the placement coordination services. Now that they're available across the province, certainly people will have a better chance of understanding which facilities are publicly funded and supervised. Clearly, all placement coordinators know that their obligation is to assess eligibility and authorize admission to publicly funded and supervised facilities: nursing homes and homes for the aged.

Often they do provide general information to families about the private sector options in their community, but they're not involved in placement in those facilities per se. I hope with PCS across the province, consumers will be better aware of the options available to them and the extent to which the province is involved in protecting their interests in those options.

The Chair: One comment and then, I regret again, we're going to have to move on.

Ms Peggy Davis: Okay, just one comment. I think the gap exists in the discharge of people by other than placement coordination services. Discharge planners in hospitals especially are not required to refer a long-term-care-eligible patient through placement coordination services. They're able to make a direct placement in a retirement home.

Just to comment on the nursing home issue, if you open the yellow pages in any phone book and look under "retirement homes" or "rest homes" or maybe "care homes," you'll see advertisements and you'll see advertised 24-hour nursing care. You'll see ads that really project a health care facility. That's all I wanted to say.

The Chair: Thank you very much. I think, as I said before, you have itemized some concerns that we haven't discussed directly. That is very helpful and we appreciate you coming to London from Windsor. It's good to see you both again.


The Chair: We then move to our next presenter, from the Independent Living Centre in London.

Mr Steve Balcom: Good afternoon. My name is Steve Balcom and I'm president of a fledgling Independent Living Centre here in London. Thank you for the opportunity of coming and speaking with you today.

As I was going over and reviewing my notes, I was debating whether to read them verbatim or paraphrase. I'm going to do a little of both, so bear with me to make sure I don't miss some of the points.


The Chair: There is time, so please feel free to make sure you get all the key points on the record.

Mr Balcom: Okay. Thank you.

The Independent Living Centre of London and Area, otherwise affectionately known as ILCLA, represents the voice of London and area's physically disabled consumers, or consumers with physical disabilities, and their needs within and out of the service system.

We have reviewed Bill 173, the Long-Term Care Act, and for our purposes the format that we chose to follow is more of questions and answers within the context of the legislation itself, or the pending legislation. So I won't be quoting paragraphs and all that stuff, but it will be apparent to those who have the act with them where I will be referring to.

Definitions: Ah, yes, definitions. In reviewing this section we noted an obvious absence of several important definitions. The definitions that we believe are lacking are:

"Individual," in our definition, one person, one specific set of circumstances, personalized;

"Consumer," an individual who utilizes long-term care functional services, a service user who is aged or has one or more disabilities;

"Agency," a not-for-profit corporation, a cooperative, municipality, board of health or band council.

I must ask, given the opportunity, can somebody please explain to me, from the previous presentation, what a care facility is as was presented in the last presentation? By my definition of where I live, it is either a support-service living unit or someone's apartment, not a care facility, in reference to where long-term care is. I would appreciate at some point a definition of what your intent is behind that, the meaning of the term so that I can understand it.

Question, and this relates back to the definitions: Will the delineation of "individual," "consumer" and "agency" be added to the bill's roster of definitions so that we're all playing with the same jargon? I have a distinct feeling, again, that what we mean by consumer and what is reflected from the Ministry of Health side as a consumer of service potentially can be two vastly different things.

Bill of rights: This section of the Long-Term Care Act is worthy of the praise being circulated by consumers within the system, as has been reflected by earlier speakers. It is the first time some of the consumers' germane or more common issues have been noted within the context of legislation, outside of the Charter of Rights and Freedoms, and we commend the act for this.

However, we are disappointed that some organizations are trying to use the term "rights" in a different context. We're running up against service providers trying to mitigate our rights and protections under, for instance, the Landlord and Tenant Act, which I believe Bill 120 speaks to specifically, and to my mind and to a lot of adults with disabilities, we are tenants in our own units, however they may be funded.

One question raised by this act is that the service provider may refuse access to records, and, if appealed, the agency may present a medical affidavit stating the complainant is incapable of attending the review, which will be accepted.

I've got to be honest; that's one area of the act that's very ambiguous, and this really concerns us and a lot of persons with disabilities. This double jeopardy situation places the consumer fully behind the eight ball. In other words, potentially it gives us no recourse as it's currently written.

ILCLA supports the consumer being present at all such reviews, every step along the way. We further support the bill of rights in this Long-Term Care Act to place an onus on the ministry to create a process by which an individual could count upon a review postponement until he or she can be present, or to provide the services required to permit the consumer to participate. That means that if they required text in forms other than written, it be provided to them; if they need an advocate to be there on their behalf, they be allowed that right.

A supplementary question revolves around this same issue about information access. This I believe I've covered under the consumer's right to have information presented in whatever form they may best be able to understand, whether that's Braille, whether that's interpreter or whatever that may be, in the appeals process so they can be aware of what is going on and be made to understand.

Within the act itself there's a statement that appears analogous to almost an umbrella statement for service providers in their responsibility to consumers. This occurs when the act states that consumers must accept the good intentions of service providers and their staff. Under the bill of rights, good intentions mean little.

Further, to date Bill 173 addresses the importance of complaint processes. However, there are no complaints featured within Bill 173 for that provision. Without it being clearly stated to them, the consumers must be aware of what their rights are. You're presuming that the consumer already has that knowledge base.

ILCLA believes that this is not the way to approach policy-making. A far more effective approach would be to work with consumers to establish a user-friendly, consistent complaint process which does not rely upon good intentions. Questions that we have are: Will consumer rights truly be protected? Will standardized rights enforcement criteria be established? Will information be provided to consumers in appropriate mediums, which was what I was referring to earlier in terms of alternative formats other than written form? Will a consistent complaint process be established?


Governance: Bill 173 states that an appointed MSA or approved agency will process, review, refer or assign individuals to required services, and in any one community there may be one or perhaps a dozen or more MSAs. There are no restrictions on their numbers and no clear criteria for them to meet. Membership and other regulatory decision-making is left to the appointed non-representative district health councils. I believe this was referred to by an earlier presentation. The only requirement currently requisite for agency participants is that they must reflect the diversity of the community. However, diversity is not defined except as an unspecified amount of representation. I've got to be honest: Those of us who have been doing advocacy in the community for a number of years have tried to get our names submitted to be on district health councils and so far, to this point, we've been pretty unsuccessful.

Obvious in their absence from all factions cited in the act are consumer representative groups. Equally obvious is the absence of choice in service assessment criteria. These are particularly important points when one considers that the decisions made by the MSAs, district health councils, consent and custody review boards and health services review boards could have serious implications for those desperately seeking services. You've got to realize that every one of those boards will impact directly on the individual consumers.


Will consumers with disabilities have suitable representation on the DHCs, MSAs, consent and custody review boards and all related decision review appeal boards?

Will there be service overlaps within MSAs? I'm sure there will be.

Are the mandatory services offered in or through an MSA deemed to be the baseline services of all Ontarians, because right now there is no clearly defined baseline.

Will consumer choice be included in the assessment referral process? Because right now there is none. MSAs are charged with referral to more appropriate services. However, this may generate a large pocket of people no one can or will service due to funding limitations and staffing caps. Where will consumers go, except to the infamous unregulated waiting lists? I think there's been enough referral to that earlier this afternoon. These have never proven an effective service methodology. The discordant nature of these modalities in availability and waiting lists have already proven to be non-beneficial. Limited service availability requires greater consideration before this act receives final reading.

There's difficulty in comprehending the lack of a standardized appeal procedure within MSAs, DHCs and all other approved agencies. I've got to be honest: That's one of the issues that we find very bothersome. People who are refused service or provided less service than they believe they require or who are facing service termination must have access to a prompt, fair appeals process. ILCLA urges the minister to address this deficiency quickly and establish a user-friendly process for consumers of services.

Again, another question: What happens to consumers when the referral agency has no funds with which to provide service? Will there be an alternative to a waiting list?

Will there be standardized appeal mechanisms in place prior to passage of Bill 173? Because right now, I've got to be honest, we feel that as consumers we don't have a voice. In fact, more to the point, we don't have a voice.

Quality assurance: Quality assurance is a necessity. Bill 173 to date fails to tell us what the quality assurances are. ILCLA wishes to ascertain precisely which standards will be utilized for comparison, how they were selected, who will monitor the compliance. That's a biggie. Who are they or the service providers that they're going to be making decisions that directly impact on consumers' lives? It seems to us and me that the consumer got lost in the process somewhere along the way. ILCLA further believes this information should be utilized in the program evaluation process. We do not believe it is appropriate to ask the lion to be the gatekeeper.

Therefore, an independent agent outside of the system would be necessary to ensure compliance and recording of this information; in other words, an independent source. You've got to remember, those to whom the money will be flowing have a vested interest in maintaining the status quo. Quality assurances are better defined by policy experts in conjunction with the consumers.

Questions: Will the quality assurance criteria be in place prior to the passage of Bill 173? Will the assurances be reflective of consumer input? Will quality assurance be utilized as an evaluative tool? Lastly, will an independent agent monitor the compliance of quality assurance?

In summary, the Long-Term Care Act is to ensure a wide range of services available to people in their homes; improve quality of service; ensure a person's needs and preferences are considered; not to be assessed once again, a big one -- some assessments are necessary but in conjunction with the individual consumer -- promote equitable access to service; promote efficient management of resources; encourage local community involvement, management and delivery of service through the MSA.

Independent Living Centre, London and Area, will not feel confident of this action potential without receiving the supplementary responses to our inquiries. Government is shifting people, programs and policies quickly. We want assurances that decision-makers have seriously considered the important issues which impact upon persons with disabilities. Thank you.

The Chair: Thank you very much. I know you raised a couple of questions where you wanted clarification, and I will ask the parliamentary assistant to do that, but first Mr Wilson for any questions.


Mr Jim Wilson: Thank you, Steve, for a very excellent brief. In fact your reputation, I want you to know, as an advocate does precede you. It's a pleasure to be here with my colleague Dianne Cunningham to see you in action at first hand as Health critic for my party. I thank you for a very informative brief.

I think perhaps, Mr Chairman, in addition to the parliamentary assistant making a couple of comments now, there are a number of very good questions. I would ask the parliamentary assistant if he would take it upon himself to ensure that Steve and his group receive a detailed response to all of the questions there, and particulary the latter ones with respect to quality assurance, because what came to mind, Steve, when you were talking about that is that we kind of have the fox in charge of the henhouse with respect to who will monitor quality insurance and ensure it. That's a point that actually hadn't been brought to our attention previously, I don't think anyway.

I did want to ask you one question, though, with respect to the bill of rights, because I think you made a number of good points about it. In your reading of the bill, are there any teeth in the legislation to back up all of the rights?

Mr Balcom: To my recollection, there is reference to the bill of rights but it doesn't extend it, it's not reinforced into individual rights. There's vague reference to it in that people have access to it. It's nice to know that those of us who lobbied to get it in place have it acknowledged that it exists, but that's as far as -- there is no -- well, two things. In terms of the legislation as it now exists, there is no empowerment, there is no inclusion of individual rights within the context of the Human Rights Code itself and how that would be implemented in any complaints process, or where it would impact or how it would be enforced, or any direct reference to it other than a very generalized acknowledgement of the act itself, which gets back to complaints and grievances and the whole bit.

Mr Wessenger: Thank you very much for your presentation. You certainly have raised a large number of questions. I will request ministry staff to provide you a comprehensive reply to your questions, but I think it might help if we had some clarification perhaps from legal counsel on some of the issues that relate to the legislation.

Ms Czukar: Initially you were discussing the issue of the definition of "care home" and whether there are common definitions. Just to clarify that, that definition of "care home" in Bill 120, which changes definitions in the Landlord and Tenant Act and the Rental Housing Protection Act, is for the purpose of those acts alone and doesn't define them for purposes of long-term care. They do that in order to clarify that people who live in a place, a home, longer than six months, and even if there is a care relationship, have the rights of any other tenant under the Landlord and Tenant Act and also the Rental Housing Protection Act. It's not for the purpose of defining the care component; it's for the purpose of defining the tenancy and the rights that people have as tenants.

The Chair: Mr Malkowski has a point of clarification which I'll deal with now.

Mr Gary Malkowski (York East): Yes, just on a point of clarification, in relation to a formal mechanism for consumers, is there a guarantee specifically that the disabled community will be involved in terms of a mechanism for feedback and for involvement in this whole process?

Mr Wessenger: I'll ask Mr Quirt to reply to that one.

Mr Quirt: Specifically with respect to attendant care outreach programs, there is a commitment that the consumers of those programs will decide whether they wish to have the government continue to fund an independent attendant care outreach program or whether they wish to receive their attendant outreach services from employees of the multiservice agency. It would fall to district health councils. I think a couple may have addressed this question already, but district health councils will have to advise the minister in the near future, canvass consumers of those programs and advise the minister as to the wishes of consumers.

With respect to the supportive housing programs for people with physical disabilities, where we provide funding for the support services, intentionally our preference is to fund a separate agency to deliver support services from the organization that is the landlord to the tenants in the building. In those situations, the multiservice agency would not have any involvement in the funding arrangement. The funding would go directly to the support service provider. Clearly the multiservice agency may refer people who could avail themselves of those services, but they would not be part of the loop, if you like, in terms of that relationship between the provider agency and the government.

The Chair: Thank you very much for coming before the committee today, as always.


The Chair: I call on the representatives from the Ontario Community Support Association, areas 1, 2 and 3, if they would be good enough to come forward. Welcome to the committee. We have a copy of your submission. If you would be good enough to introduce yourselves, then please go ahead.

Ms Sue Hillis: Good afternoon and thank you for the opportunity to present today. I'm Sue Hillis. I'm the director from area 2, and this is Heather Richardson, the director from area 3. Our presentation will begin today with a brief overview of who we are and we'll follow this with our key areas of concern with the legislation.

The Ontario Community Support Association is an organization of direct providers of community-based services. Our primary purpose is to support, promote and represent the interests of community-based not-for-profit health and social service agencies across Ontario. In over 300 member agencies across the province, our organization provides community support services to the elderly, people with a disability and those convalescing from an illness to enable them to live safely and happily at home. Over 10,000 dedicated staff and 45,000 active hands-on volunteers work diligently to provide a wide range of services. Many of our volunteers are seniors themselves. In 1993 these volunteers donated over 1.2 million hours of service.

Each year more than 600,000 Ontario residents receive help from community support service programs. OCSA tries to work with governments, related associations, the general public and the private sector to develop innovative and responsive strategies to expand community support services and to support the efforts of seniors and others with special needs to remain independent in their homes.

OCSA is divided into 15 areas, which form the foundation of the association. Through this area structure members are able to have an equal voice in the association while allowing each area the flexibility to respond to the needs identified by its own membership.

Today we are presenting on behalf of areas 1, 2 and 3, which encompasses Essex, Kent, Lambton, Elgin, Middlesex, Oxford, Perth, Huron, Bruce, Grey, Dufferin, Waterloo and Wellington county member agencies, approximately 80 agencies, a good cross-section of both urban and rural.

The membership of OCSA supports several aspects of Bill 173, An Act respecting Long-term Care. We endorse the principles and values enunciated in Bill 173. It's been these principles that have guided our response today.

We support not-for-profit service delivery where the principles of community-based planning, equity of access and equality of services prevail. We are committed to the development and implementation of standards of care and the continual improvement in the level of service quality.

Based on the input form those member agencies I've mentioned before, we would like to present area 1, 2 and 3's five key areas of concern with this legislation. They include the following: areas not covered in the legislation; the regulations; volunteerism in the reformed long-term care system; multiservice agencies; and categories of services. Heather Richardson will present a more detailed assessment of these issues within each area of concern and suggest recommended strategies for improving the legislation.


Ms Heather Richardson: Areas of concern, areas not covered in the legislation: In the document Partnerships and Long-Term Care: Guidelines for the Establishment of Multi-Service Agencies, released in September 1993, messages regarding the perceived preferential treatment of unionized employees in the new MSA became apparent. Subsequently, in Bill 173 there were no references regarding the protection of not-for-profit community-based employees as a result of implementation of long-term care reform.

Long-term care reform acknowledges the need for experienced, trained staff for the provision of services, yet the proposed process for development of multiservice agencies, along with social contract reductions and constrained finances, all currently have or will potentially have a negative impact on employment in the broader socio-healthcare sector.

Although there are similarities between clients in institutional settings and those in the community, the environments are quite different. Therefore, special consideration is required when transferring staff from facilities to community-based agencies. For example, there are differences in the skill sets and goals of care, or methods of achieving those goals.

A forgotten group of employees who work through brokerage agencies should have their experience recognized in this process.

The community support sector consists of over 10,000 employees who are experienced and trained in the care and delivery of services. These staff have worked for years at low wages and minimal benefits with a strong commitment and loyalty to providing quality services. Unionized employees in the broader socio-healthcare sector are demanding priority employment in the community sector. Our sector is predominately non-unionized and thus less able to voice concerns than organized labour bodies.

There will be significant human resource issues which will require expertise, time and financial resources in order to be addressed successfully.

OCSA recommends that client continuity and respect for the relationships between existing employees and consumers of service should be paramount. Consequently, employee transfers to new agencies should be seamless, with no break in employment or client service.

All employees of not-for-profit community support service agencies should be guaranteed comparable positions in the new service delivery structures, without loss of seniority. Otherwise, in all community support sector hiring, displaced employees from not-for-profit community sector support agencies should be given priority over other socio-health sector employees.

General regulations: It is our view that Bill 173 has taken an overly prescriptive approach to the provision of community-based services. Some 42 regulations have yet to be produced. Much is unknown at this point, yet the areas to be covered appear to be quite prescriptive. It is difficult to present a response to the legislation in the absence of the detailed information which would be in the regulations.

Bill 173 allows for the provision of regulations to be retroactive. However, MSAs will be developed over a period of four years. Consequently, it will not be feasible in certain instances to make the regulations retroactive.

The province is moving quickly to put MSAs into practice, yet major components need to be put into place; for example, eligibility criteria, program standards, MSA guidelines, regulations. OCSA says that we must be actively involved in producing and approving the regulations to be developed in Bill 173. Furthermore, OCSA recommends that extreme caution needs to be applied in setting retroactive dates of application.

Volunteerism: In addition to their valuable work in service provision, a significant amount of money is made available for services as a direct result of the fund-raising efforts of volunteers. If volunteers are not properly maintained, costs will skyrocket; thus, MSAs will not be cost-efficient and the ability to meet existing consumer needs will be jeopardized.

There is a lack of detailed planning regarding volunteers and long-term care, even though there is a concern about an inadequate number of volunteers currently to support the expansion of programs and services. We recommend that volunteers should be kept well informed and actively participate in the change process in the implementation of long-term care reform. Furthermore, sufficient resources to support a volunteer management structure which includes recruitment, training, scheduling, supervision, retention, recognition and expense reimbursement of volunteers at the natural community level should be provided on an ongoing basis. Volunteers are motivated by an array of factors and cannot be shifted organizationally away from their work without risk of loss. Therefore, it is absolutely vital to maintain the linkages between volunteer tasks, their communities and the agency staff that sustain them.

Multiservice agencies: It is essential that there be sufficient flexibility to allow communities to develop an MSA system to meet local needs. It is unclear what the final MSA model will look like in each community until the community planning process is over. Consequently, it is premature to assume that the same model will meet the needs of all residents in Ontario.

One-stop or single access does not necessarily mean that all services and care providers have to be assembled under one roof or that consumers have only one point of contact in a community. It may, for example, be achieved by a functional integration of information, referral, assessment, case management, service delivery and follow-up in multiple locations. On the other hand, we must ensure the client does not become discouraged by being referred to various services, as is currently the practice. OCSA believes that MSAs must not be allowed to develop into large bureaucratic organizations. They must be small enough to be able to be responsive to local community needs.

Improved coordination and access to available services are highly desirable. Close coordination will be needed if there is more than one point of contact in a community. Communication among providers is key. Functional integration of information could be achieved through electronic communication systems and/or by combining physical locations for smaller community support agencies to achieve economy of finances and volunteers.

OCSA recommends that if functional integration is pursued, top priority must be given to ensuring there is an effective computerized information network in place. This must include a financial commitment to design, hardware, software, training and support.

Categories of service: The separation/distinction between community support services, homemaking, personal support services and professional services reinforces a hierarchy of services ultimately geared to medical needs rather than fostering a continuum of care. It reinforces a split between health and social services and moves away from wellness, health maintenance and prevention measures. This is inconsistent with the purposes of the act. It will be confusing to the client and the case manager, who will be pressured to approve the need for personal care.

The distinction between personal support services and homemaking services appears to be contrary to the current trend to develop a "generic" worker which would combine health care aides, homemakers, home support workers, home helpers and attendant care workers. In most agencies, both personal support services and homemaking, as defined in the act, are provided by the same person. These services are provided concurrently and this worker will be the recipient of the recently developed training program. The inclusion of these two services separately in the legislation is a major step backwards and could interfere with the development of a generic worker.

There are also concerns about how these two services will be operationalized. This separation will be an administrative nightmare for the service provider or approved agency. For example, how does the service provider manage the client who requires a bath (personal support services) and laundry, shopping and housecleaning (homemaking)? Both services are important in terms of maintaining the client's independence in their home. Will the time be prorated?

New terminology is being used, and initially this may lead to some confusion in the community. "Personal support services" was known as "homemaking." "Homemaking" is being used to describe tasks previously referred to as "home help." It is recognized that the terminology currently being used varies considerably across the province and there is a need to have standardized definitions. A definition of services to be provided by MSAs must allow for flexibility to encourage the development of innovative programs, which can be more effectively and efficiently developed through a community development process. OCSA recommends that the artificial distinction between homemaking and personal support services be ended by combining them. OCSA would like to be involved in the development of a new term to describe the service.


The user fee issue should remain separate and not be included in this legislation.

It is important that a comprehensive communication plan to educate consumers and service providers on the changes in the system be developed. Change is often difficult and confusing, especially for a consumer.

Ms Hillis: We applaud the leadership demonstrated by the provincial government through the development of Bill 173, which establishes the key building block in the foundation of the new long-term care system. We appreciate the commitment to building partnerships with the community to effectively plan and implement meaningful change.

Given the time constraints for today's presentation, we have given you a more thorough summary of our concerns in writing from our area. As well, I understand you also have a copy of the full OCSA membership response, which presents areas of Bill 173 that we endorse, our areas of concern and recommendations in much greater detail. We look forward to working in continued partnership with the government and our community colleagues to bring about the redirection of the long-term care system and will be happy to answer any questions that you might have about area 1, 2 and 3's concerns about the legislation.

The Vice-Chair (Mr Ron Eddy): Thank you for your presentation. A question by Ms Haslam, please.

Mrs Haslam: I was present when this was presented to us in another area. I didn't get to make any comments or ask questions at that time, so I'm certainly going to take advantage of it now.

Number one, I firmly believe in what you're talking about when you talk about the computerization and those kinds of networks that are so important out there. That takes me back to one of your previous comments on page 5, where you said providers have to be assembled under one roof. That's not what the legislation is saying. We're not saying that you have to build a building and move everybody under one roof; we're talking about networking of services.

I don't know why they didn't take my advice a long time ago when I said instead of naming it MSA, why didn't they call it the area services coordination, and then it could be called ASC, and your seniors, then, when they have questions, don't have to call an MSA; they could call ASC. Nobody ever listens to me with these acronyms. What can I tell you?

The second thing I wanted to mention under your presentation is on page 3 when you talk about reductions and constraints of finances. I just wanted to remind you that in 1990-91, long-term care community funding was $550 million. In 1993-94, that's been expanded by 54%, to $850 million, and by the fiscal year 1994-95, we will be spending over $1 billion in long-term care community-based services. I think that has to be out there in the public so they know that those moneys are being put into the community.

Which brings me back to page 5 and the volunteer portion of your presentation. It's an area that I take a great interest in. You talk about a volunteer management structure. I don't know if you know there is going to be a series of forums cosponsored by the ministry and the Association of District Health Councils and the United Ways of Ontario which will examine volunteer recruitment, retention and fund-raising in the new system.

When you come with concerns about that, what shape do you see it taking? What shape do you see that volunteer structure, what form, the number of people and how it might be managed, and what suggestions would you give to your local process? It's a local process of putting in your MSA. It's the local input that will address how that looks in your community. What would you be saying on that committee when you discuss how to keep the volunteers active in your MSA?

Ms Hillis: I guess one of the big points that would strike me right off is that it's really important for volunteers to be able to identify with what service they're providing.

Mrs Haslam: Like program sections, yes.

Ms Hillis: By program or by service or whatever, because people often volunteer for specific things for personal reasons.

Mrs Haslam: Sometimes.

Ms Hillis: We find that often in several of our services, anyway. So I think it's really important that they're brought along very slowly, that throughout the whole process they're asked what's most important to them, and that they can retain some identity with the program as it progresses through to whatever structure it's going to be in the future. I think unless we bring them along slowly throughout the process, we will lose them along the way.

Mrs Haslam: So give them as much input as possible into how a structure manages and funds them, if necessary, and trains them.

Ms Richardson: I would like to make a comment to the amount of money that is being put into the system. Certainly, looking at the demographics that we're going to face over the next century coming to us, we are going to have to put considerable resources in. It is understandable that this is a beginning of a curve of resources; however, as we have noted in previous presentations, the waiting lists are not getting shorter, because of course the demographic issue does face us very strongly.

Also, as you may know, IHP in many areas is capped. There is the possibility that supplemental budgets are not going to be filled in terms of home care. And of course, as you know, the social contract has meant -- although primarily our concern is for the clients as it relates to those supplemental budgets and IHP caps and waiting lists, certainly there is a notation regarding staff, that most of the staff are lower paid than in the hospital sector and yet they are not having increasing remuneration because of the social contract. So there might be a thought in terms of the moneys going into the system being demanded by the demographic curve.

The Vice-Chair: Thank you for your presentation.


The Vice-Chair: The next presentation will be made by the medical officer of health of the Middlesex-London Health Unit. Welcome to the committee.

Dr Graham Pollett: Thank you, Mr Chairman, members of the committee. My name is Graham Pollett. I'm the medical officer of health for the Middlesex-London Health Unit. With me today are Councillor Ted Wernham, a member of the board of health, and Mrs Patricia Coderre, the director of the home care program. We appreciate having this opportunity to contribute to the review of Bill 173.

To begin with, I would like to provide you with some background information regarding the Middlesex-London Health Unit. The Middlesex-London Health Unit was formed in 1971, following the merger of the city of London and a number of Middlesex county health units under one board of health. In 1972, the new board accepted responsibility for the school health service, which had previously been provided by the city of London board of education. The home care program, which had been initially administered in this area by the Victorian Order of Nurses, became the responsibility of the board of health in 1980 and has functioned as a division of the health unit since that time. A four-year accreditation award, the maximum given by the Ontario Council on Community Health Accreditation, was granted to this health unit in 1993.

The catchment area for this health unit is, as its name implies, the county of Middlesex and the city of London. This area includes a population of approximately 320,000 people. The health unit consists of a multidisciplinary staff of 310 operating out of a main office in London and a satellite office in Strathroy.

The Middlesex-London Health Unit is governed by an autonomous board of health, as opposed to many Ontario health units that are part of a municipal structure. Presently, membership on the board consists of three city of London council appointees, three Middlesex county council appointees and two provincial appointees. The duties and responsibilities of a board of health are defined in the Health Protection and Promotion Act. This act was proclaimed on July 1, 1984, and it replaced the Public Health Act.


Section 5 of the Health Protection and Promotion Act defines seven programs and service areas which every board of health must provide or ensure the provision of. These include community sanitation, control of communicable diseases, preventive dentistry, family health, nutrition services, public health education and home care services.

Prior to and following the proclamation of the Health Protection and Promotion Act, this health unit has been mandated to provide home care services within Middlesex-London.

The Middlesex-London board of health is on record as strongly supporting the principles and goals of long-term care reform stated in the ministries of Health, Community and Social Services and Citizenship document entitled Partnerships in Long-Term Care: A New Way to Plan, Manage and Deliver Services and Community Support -- Guidelines for the Establishment of Multiservice Agencies.

Upon review of these principles and goals, and based on our history and legislated mandate for service delivery, the board of health has initiated action with the objective of representing this community as a multiservice agency. The first step in this process was the development of a Middlesex-London Health Unit multiservice agency model. We have included a description of this model with copies of our submission.

Bill 173 defines the criteria for establishing and operating multiservice agencies. The Middlesex-London board of health has identified two concerns which we will address today. The first relates to the establishment of multiservice agencies and the second concerns an operating dimension.

Part VI, section 11, subsection (3) of Bill 173 reads as follows:

"Before designating a municipality or a board of health as a multiservice agency for a geographic area, the minister shall consider the suitability of all other approved agencies in the geographic area for designation as multiservice agencies."

In effect, this subsection disqualifies health units from becoming a multiservice agency. In the case of this health unit, the opportunity to compete is essentially eliminated because there are so many local agencies which must be given prior consideration.

Why is this subsection included in this bill? What direction is it giving to those making decisions regarding the establishment of multiservice agencies? And what message is it giving to boards of health?

As mentioned, this board of health has been administering the home care program for the past 14 years. In so doing, it has been responsible for providing those community services defined under Bill 173 as homemaking services, personal support services and professional services. In addition, staff of the Middlesex-London Health Unit home care program administer a $1-million meal services budget as well as having, on an ongoing basis, direct contact with providers of the remaining services designated under community support services.

Similarly, 32 of the 38 home care programs, 32 of the 38 integrated homemaker programs, 32 of the 38 assistive devices programs and 12 of the 36 placement coordination services are administered provincially by public health units.

At no time over the past 14 years has this board of health been advised by the Ministry of Health of any dissatisfaction or concern with the manner in which the services we deliver were being administered. We are left at a loss to explain this situation.

There is no other community board in Middlesex-London that has the experience for administering the range and volume of community-based services that this board of health has. There is no other existing community-based agency in Middlesex-London whose staff have the expertise for administering the range and volume of community services that staff of the Middlesex-London Health Unit have. There is no other community-based agency that integrates health promotion and protection, disease prevention and treatment services at the community level for as large a population as this health unit does.

As a board and as staff, we are left in the worst possible situation: not knowing the reasons for our apparent exclusion and therefore not able to directly address the rationale behind this decision. Recognizing this dilemma, we would like to briefly speak to a number of issues which could have contributed to the wording of section 11, subsection (3).

The first pertains to the composition of boards of a multiservice agency. Currently, the membership of most, if not all, boards of health, including the Middlesex-London board of health, does not meet the requirements for those of multiservice agencies. It is important to remember that boards of health and health units are creations of the provincial government.

The composition of a board of health is defined by statute: the Health Protection and Promotion Act. Changing the sections of this act related to board composition would achieve the community involvement objectives intended for multiservice agency boards.

Secondly, if there is a concern that health units are headed by physicians, a change in the section of the Health Protection and Promotion Act designating a physician as the chief executive officer could likewise be made.

The hospital sector is an example where this change was long ago instituted. Further, it is important to remember that physicians make up less than one half of 1% of the multidisciplinary staff complement of any health unit.

An opinion expressed by some is that health units practise the medical model and, for this reason, they should not be considered eligible as a multiservice agency. For those of us in health units, this is particularly upsetting. Nothing could be further from the truth in 1994.

Public health has been instrumental in initiating the practice of health promotion, where the health care provider is seen as a facilitator to assist the community and its member to achieve their health goals, as opposed to prescribing actions or treatments for people.

Advocating with and for clients has been a part of public health since its inception, as has the focus on disease prevention and health protection. But over the past 20 years, there has been a dramatic shift to a practice based mainly on health promotion principles. In fact, other community agencies and institutions are adopting the health promotion approach based on the leadership provided by public health.

A final point which may have influenced those drafting section 11, subsection (3), is the perception on the part of some people that the health unit, in particular the staff of the home care program, are bound by a bureaucratic approach to administering programs and services.

In the home care program, we have been given the task of implementing Ministry of Health policies, procedures and eligibility criteria. We have done this and continue to do so in a professional, compassionate manner. This is a job that is not always easy and is rarely appreciated, especially by those who find fault with the service.

The need for this role will not change in a multiservice agency. No matter who makes the decisions at the local level regarding the distribution of scarce resources, there will always have to be a messenger charged with delivering and implementing those decisions. Then, as now, don't shoot the messenger.

Are any of these factors the reason behind the inclusion of section 11, subsection (3)? Is it a lack of understanding of public health philosophy or how public health units operate? We simply don't know.

Whatever the reasons, it is our opinion that Bill 173 completely ignores a proven, well-organized system already in place for the delivery of long-term care services. Rather than building upon the strengths of this system and addressing its limitations, Bill 173 effectively eliminates public health units from being considered as multiservice agencies.

We therefore urge you to reword section 11, subsection (3), such that all community-based agencies will be given equal opportunity to be designated as a multiservice agency, or eliminate subsection (3) entirely.

The second concern we have with Bill 173 relates to the operation of multiservice agencies as defined in section 13. This section will result in the integration of a minimum of 80% of service providers as employees of a multiservice agency. Non-profit and for-profit service provider agencies will be left to compete for the remaining 20% of the amount budgeted for any one of the four categories of community services. Even this amount of expenditure for external purchase of service is not secure, being at the discretion of each multiservice agency board.


As a result, most agencies providing services under the current home care program will not be viable operations and those remaining will be reduced essentially to the role of temporary employment agencies. This, in effect, will greatly reduce opportunities offered by a competitive marketplace.

Further, in our opinion, this situation represents unfair treatment for those non-profit and for-profit agencies which have provided and continue to provide an essential component of the home care program. Many of these agencies in the non-profit sector have a long and distinguished record of public service. In addition, within Middlesex-London, the home care program has encouraged and fostered the growth of a number of for-profit agencies simply because the non-profit sector was unable to handle the volume of service delivery required.

We contend that each multiservice agency should focus on coordination and administration of a one-stop access mode of long-term care service delivery, but leave the actual hands-on service provision to those agencies with proven expertise in this area.

We therefore request that section 13 of Bill 173 be deleted. The current wording of section 12 allows for flexibility in the type of approach chosen by each multiservice agency board; that is, contract for service, integration of service provision or a combination of these.

In conclusion, we wish to thank you for the opportunity to appear before you. While we are generally in support of Bill 173, we have identified two areas which cause us concern as a community-based health agency currently providing long-term care services. We hope you will give serious consideration to our concerns in your final recommendations for changes to this legislation. Thank you.

The Vice-Chair: Is there any other comment from either of the others? Questions? Mrs Caplan.

Mrs Caplan: Excellent presentation. I thought of a couple of other things that you hadn't mentioned and that I would like to put on the record, given some of my prior life. I always found that the boards of health and the health units, public health generally, had an excellent leadership role in outcome evaluation, the kind of quality development in their programming based on analysis that provided models for other service providers.

I just thought I'd mention that, because it wasn't in your presentation and it is something that the boards of health were ahead of everybody else on. When we were looking at bringing the notion of quality assurance and continuous improvement into health policy and health reform, the boards of health did provide an excellent model.

I think your question deserves an answer and I'm going to ask the parliamentary assistant, since this is a matter of policy, if he could tell us why the legislation has effectively excluded, or at least if not totally exclude, discriminated against the ability of boards of health and health units to become the MSAs.

Mr Wessenger: Yes, I think it's fairer to characterize the provisions as not prohibiting, but --

Mrs Caplan: Discriminating.

Mr Wessenger: I think that's fair, yes, giving a preference to non-profit organizations. Certainly, I think, one of the issues that has been raised by the board is quite accurate with respect to one of the considerations, and that is the governance model. I certainly was very interested to hear their suggestions that that could be changed.

I think the other aspect is that in the province of Ontario we've had a long tradition of providing our health services and our social services through the non-profit, voluntary model. If we look at our hospitals, if we look at our social services, that's been the major method by which we developed delivery of services through the province. Boards of health are deemed, I suppose, as governmental models, as distinct from the voluntary, non-profit model, and I would suggest that's a major reason for the preference for the agencies which have a volunteer, non-profit model.

Mrs Caplan: At the back of their presentation, they state what is in the Health Protection and Promotion Act which permits, without a change in legislation, the balance on the existing boards of health to be one less than the majority of consumer appointments, if you will. I'm going to use that one specifically because that's your MSA model, and I would argue that the MSA model is almost possible without any amendments to the legislation. There are some boards already in the province that reflect that balance -- not many, but there are some -- and it is certainly possible for that to happen under the existing legislation.

Secondly, it would be a minor change in the legislation that I think would be supported by both the boards and the units to that kind of model. The notion that the boards are governmental versus community, I think, is an insult to the boards and to the health units, because while they have dual accountability back to the local councils as well as to the Ministry of Health, from the fact that they are receiving funding from both for their program delivery, in many ways, from my experience as a former member of a board of health -- actually, I used to joke and say that I had difficulty in becoming chairman of our local board of health; there were some local politics going on, so instead I decided I'd like to be Minister of Health.

The Vice-Chair: We'll excuse the comment. Proceed.

Mrs Caplan: I just make that as an aside to let you know of my long-standing history as a former member of a board of health. I do think that if the concern of the government is only the governance issue, then that could be accommodated by some minor changes, and that boards of health and health units should be considered, because I think the expertise is there already. The points that are made in this presentation are excellent and would be mirrored by numerous other boards and units across the province. So I'd like you to consider that.

The last question that I have really is of Dr Pollett, and that is, why did you leave North York?

Mrs Cunningham: Welcome to London. There's no answer.

The Vice-Chair: Realizing there could be several answers, we'll proceed. Did you want to comment briefly, or we'll move on. I've been asked by Mr Winninger for the opportunity to ask a very short question, I understand.

Mr Winninger: Yes. Actually, it's a comment because my line of questioning, as it transpires, was similar to Ms Caplan's. But I don't read that subsection 11(3) quite as narrowly as you do, and I don't think in any way it spells out a preference for an agency other than a district health council.

Mrs Caplan: Oh, it does.

Mr Winninger: It seems to me that if there were community consensus and the board could be reconstituted in a manner that matches the requirements of the MSA, there's nothing in that section that says that the minister shall actually choose another agency before you. It says that the minister shall consider the suitability of all other agencies, but it doesn't draw any conclusions in that respect. I think we have to be very careful to say that there might be a preference there, although the parliamentary assistant seems a little agitated --

Mr Wessenger: No, no.

Mrs Caplan: Well, it does discriminate against boards of health.

Mr Wessenger: I would just like to confirm that I would agree with Mr Winninger's interpretation that if your long-term care committee makes that proposal and has taken everything into consideration, certainly there's no prohibition, so I think it's still open.

Mrs Cunningham: So we can clarify it with an amendment.

Mrs Caplan: If I could just clarify it, because that was my line of questioning, am I hearing from the parliamentary assistant that it is the policy of the government not to discriminate against boards of health and health units in the determination and designation of MSAs?

Mr Wessenger: I think it's fair to say it's the government's position there's a preference for a non-profit agency, but I don't think there's anything in the process that prohibits a board of health from trying to reconstitute itself -- I don't know what is possible -- to fall into the category of a non-profit, charitable --


Mrs Caplan: But the problem is that as the legislation is written and there is a clear preference -- that is the word you use -- and discrimination against boards of health. You have a preference for other than boards of health and I'm saying there's a discrimination against boards of health. Unless you're prepared to clarify the legislation, then in fact those community organizations, groups, committees of the DHCs and so forth will read this legislation and say, "We really have an obligation to give everybody else preference."

I think that if your policy is as you're stating, and that if it -- with some governance changes that you would have no problem. I would hope the government would bring forward an amendment to this legislation that would clarify that because, as it stands right now, you're discriminating against boards of health.

Mrs Cunningham: We're putting forth an amendment in that regard.

The Vice-Chair: Thank you. Any further comment by the --

Mrs Cunningham: Mr Wessenger agrees with it and so does Mr. Winninger.

The Vice-Chair: Please.


The Vice-Chair: Thank you for bringing further discussion before the committee. We appreciate that. You're all most happy I see, so any final comment? Then we'll let you go.

Dr Pollett: We simply want the opportunity to compete on an equal footing.

The Vice-Chair: Thank you very much for your presentation. We note that.


The Vice-Chair: The next presentation will be made on behalf of the Kent County District Health Council by several representatives.

Mr Bruce McCallum: I would like to introduce the group appearing before you at this time. My name is Bruce McCallum. I'm chair of the long-term care steering committee and a member of the Kent County District Health Council. I have with me another member of the district health council, Mrs Mary Lee -- and it shouldn't be too difficult to determine which one is Mrs Lee -- as well as Mr Paul Balkwill, who is a member of the long-term care steering committee and chair of the MSA committee, and Mr John Ferguson, who keeps us all honest; he is Joe Consumer.

The Kent County District Health Council supports and applauds the efforts of the current government to make the necessary legislative changes which will enable long-term care planning committees to move forward in the implementation of long-term care reform. Bill 173 will provide the legislative framework required in order to implement proposed changes to the current system of long-term care services. Consumers of long-term care services will soon find themselves accessing a well coordinated range of health and home support system of services.

The new system of long-term care services will reflect many of the suggestions and changes that consumers have proposed over the last several years. On behalf of the long-term care steering committee of the Kent County District Health Council, I would like to thank the standing committee for their efforts to date and for the opportunity to present our response to Bill 173 today.

The Kent County District Health Council participated in the preparation of two responses to Bill 173. Both of these responses will be presented this afternoon to the standing committee on social development.

The first of these responses is a submission from the District Health Councils of Southwestern Ontario which will be presented later this afternoon, I believe at 4:30. As a member of the District Health Councils of Southwestern Ontario, the Kent County District Health Council supports the submission of this conjoint response to Bill 173. This response addresses the proposed amendments to the Ministry of Health Act. The proposed amendments will have implications for the role of district health councils in long-term care planning.

The Kent County District Health Council also supports the following submission by the long-term care steering committee that's appearing before you now.

This long-term care steering committee assigned a special work group to review Bill 173 and to prepare a report for presentation to the standing committee on social development here in London today. The Bill 173 work group consisted of five volunteers and one staff member, and the long-term care steering committee acknowledges the efforts of this committee to collaborate on this important task. The following report summarizes the results of the work group's efforts.

We've taken Bill 173, which I'm sure all of you must know by heart by now, and we'll just comment very briefly on these items.

Part I: Generally, the purposes of the act support the policy directions of long-term care and the local planning process to date.

Clarification is needed in terms of how health and social services will be integrated. Does the term "community services" used in clause 1(a) include both health and social services?

Further definition of "people," as described in clause 1(a), as the target population is suggested. For example, who does this include or exclude? The links to other populations, such as the developmentally handicapped or those with a mental illness, are not clear.

Acute care as a component of long-term care is not clearly identified or addressed in the document.

Part II: It is suggested that meal cleanup be added to the list of homemaking services in subsection 2(5). It is also suggested that in subsection 6(2), "personal activities of living" be reworded as "personal activities of daily living."

Part III: Generally, the concept of the consumer bill of rights is supported. Under the act, the right to appeal will be clear to the consumer.

Part IV: In subsection 4(1), the position of director needs to be clarified. Despite the definition provided in subsection 2(1), it still is unclear what department or agency the director will be responsible for.

Part V: In clause 7(1)(b) and subclause 44(1)(c)(vi), concern is appropriately expressed for the health, safety and wellbeing of the person receiving services. Should the same concern not also be extended to the workers providing these services?

Part VI: This section supports some flexibility in providing optional services. This may allow local planning bodies to recommend services which are tailored to meet the unique needs of their local communities and to complement existing resources. However, it is unclear what resources will be allocated to these optional services, given that most of the funding envelope will cover the costs of the mandatory basket of services.

In section 13, the 20% limit on purchase of service is clearly outlined. However, another ministry document stated, "The purchase of services from commercial agencies will be limited to a maximum of 10% of MSAs' homemaking and professional services budgets." This statement appeared in the Implementation Questions and Answers dated June 6, 1994. If this is true, should this guideline not be included in the act?


In clause 13(3)(c), the act describes the purchase of service from an individual. How does this individual qualify for an exemption from the 20% limit on purchase of service? The direction that the members of the agency's board of directors reflect the community on the basis of gender, age, disability, place of residence, as well as cultural, ethnic, linguistic and spiritual factors, may make the democratic process of selection impossible.

The long-term care steering committee is concerned that the validity of an agency could be continuously open to challenge based on a perception of the failure to comply with any one of the factors outlined in article 2(a) of the act. The committee recognizes by policy direction that an MSA board would be elected by its membership, but this is not supported by inclusion in the act.

In part VII, the committee feels that quality management referred to in section 24 should be designed by local MSAs.

Accreditation is not mentioned in the act. The committee feels the concept of accreditation needs to be included in the legislation of Bill 173.

Part VIII: The committee supports the act of participation of the consumer in the development of the plan of service.

Part IX: Who is the appeal board as defined in the act? Is this board in existence or is it a proposed board and, if so, who recommends membership on this appeal board?

Part X: Does subsection 50(4), obligate a service provider to provide care to someone who is not eligible for services? Could this subsection obligate a service provider to provide care for someone who is not eligible for service under the act?

Part XI: Section 56 addresses the role of the Lieutenant Governor in prescribing additional services. What is the role of the district health council in making recommendations on increasing service levels? For instance, can an agency apply directly to the ministry, or will the district health council consider this increase within the context of the broader picture of planning an integrated system of long-term care services?

The same line of questioning can be applied to paragraph 56(1)9 in terms of the role of the district health council in making recommendations on the allocation and reallocation of funds.

Paragraph 56(1)22 addresses the collection of information. Some of this information is essential to the planning process. What provisions in the act allow for the sharing of information between long-term care area offices and the district health councils, in order to allow for planning which is based on reliable and accurate data? Presently there is a duplication of the collection of information by government agencies and planning bodies due to restrictions based on confidentiality.

Part XII, subsection 61(1), addresses the role of the district health councils in planning. If district health councils are to make recommendations on the allocation of resources, they need to have access to information on financial resources in order to do so. The act does not address the accessibility of these resources in order to meet the mandate as indicated. There is some indication that the district health council and members of the public should have access to information relating to the present activities of the service provider and the future direction of the provider. The long-term care steering committee respectfully asks the standing committee on social development to carefully consider the suggestions in this report when making amendments to Bill 173.

I think the feeling is this bill is about care of consumers in their home, based on what the community determines as its needs within a framework of government funding and supplementary volunteers and local funding.

Could the bill be more consumer-friendly? It's a word we hear in communication these days and this group of consumers, or about to be consumers, some of us -- I'll let you draw your own conclusions there -- we realize that bills have to be made in an appropriate way, but communication's changed a lot since this format was first devised, I'm sure, and it would certainly assist planning bodies such as the long-term care steering committee to have it in plain, understandable English, the same as insurance companies did with insurance policies a few years back.

That, ladies and gentlemen, is our report and I'd be most happy to refer questions to my colleagues.

The Vice-Chair: Thank you very much for your presentation and I note that there are a number of very important serious questions that you may or may not expect responses and answers to today, immediately.

Before calling on the parliamentary assistant to respond in what way and what time frame he can answer these various questions, I would ask Ms Cunningham if she has a question at this time first.

Mrs Cunningham: First of all I'd like to thank the group for your work because you've given, I think, a lot of thought to this presentation on a lot of specifics. I think, Mr Chairman, with respect, that any answers the parliamentary assistant could come up with today would perhaps not be very helpful, because you've asked so many questions and maybe what you'd like to have is some kind of a response to your brief in writing. I make that suggestion because I myself would like to see the answers to the questions; they are very well-thought-out. So, Mr McCallum, I hope you'll get a response in writing to your questions.

Earlier today we heard from a number of consumers but specifically, I think, this afternoon as we listened to Mr Balcom of the Independent Living Centre -- he was a consumer and he used the same concern that you have, this user-friendliness.

Can I ask a question with regard to perhaps your own area -- you can give us an idea -- how do you think the ministry will be able to choose in your area, given the work that you've done, a multiservice agency? Do you, as a district health council now, think you have a group or an agency that could respond to this request?

Mr McCallum: Yes, I would like to refer that question to the chair of our multiservice agencies subcommittee, who has been working on it diligently for the past year. I'll let him take the -- it's going to be presented to the public and the community for further discussion very shortly. Paul?

Mr Paul Balkwill: Thank you, Bruce. To Mrs Cunningham, Mr Chairman, our multiservice agencies subcommittee has put forward a design for a community health and support services agency. We've changed the name already to the long-term care steering committee and we believe that over the four-year period we've been given we can work through a transitional model to a full-blown multiservice agency.

There is a real concern that we have as a subcommittee group, and it is the issue of governance and it's been mentioned several times here today while we've been sitting here. If you accept that all of those areas mentioned in the bill must be reflected in the governance model, then the question is how big a board is this? This was put directly to me and I said, "I think that maybe a minimum would be 12, but probably you'd have to extend it to 20." Then, in fact, to be able to get the representation the bill suggests should be there begs the question of whether it can in fact be a democratic process. I put that to you because if you're dealing with a county, for instance, and you must have geographic representation and then you must have spiritual and linguistic and all those other representations, and then to expect that it will be a truly democratic process -- I don't know. We're really struggling with that and if the government can help us out in terms of how you'd go through that process to get a truly representative, truly democratically selected body, we'd really be interested.

Mrs Cunningham: I thank you for that response, because there are certainly other areas of government right now that are spending more time and more energy, and you know how important it is if we're talking about taking care of people here. That's where our energy should be, in making up their boards. For instance, in community colleges right now, the boards are spending all of their time fighting with the government as to who they can have on their own local community college boards. I don't want this to happen in this regard -- not that I even like the concept, that's why I was asking you. By example, the previous presenters felt they were excluded, and yet they may be the best agency.

I thank you, and I hope we'll be free to talk in the future if we get into some difficulties during the drafting of the amendments with regard to this issue that you brought forward today, along with the others.


The Vice-Chair: Parliamentary assistant, please.

Mr Wessenger: I think the best way is to write back to answer some of the questions you've asked. With respect to the whole question of board composition, though, I think it's fair to say that there's not going to be a prescription laid down that every group has to be represented. I think the minimum requirement is going to be that there's going to have to be consumer representation on the board, and the way most voluntary organizations work, through their nominating committee process they try to ensure that the people nominated for the board reflect the diversity of the community, but sometimes that doesn't work out, and that's understood that sometimes that doesn't work out. But that's the way it would be anticipated to be done, not a rigid requirement or prescription and bylaws that every group is represented. There would be a prescription certainly with respect to ensuring that a third of the membership would be consumers, but as far as I can see, that's about the only prescription that would specifically be there.

The Vice-Chair: So the ministry will be forwarding answers to your questions and circulating it to the members of the committee for information.

Mr McCallum: If I might ask a question of the Chair, if we have any time left, we have a question raised by one of our members here. If we have any time left, with permission of the Chair, I would like her to ask that question.

The Vice-Chair: Proceed, please.

Mrs Mary Lee: Thank you, Bruce. Thank you, Mr Chairman, ladies and gentlemen. I'm pleased that you've given me the opportunity to speak. I am a city council appointee to the district health council to the long-term care committee to the MSA, as was requested, and I represent them today, not city council.

However, I brought up the fact that there is a bill called 173 to my city council last week. Not one of them had a clue that it even existed. I referred it to the administration and to the social work department and I guess the clerk's department to have them review it and come up with some recommendations or critiques or something. However, I discovered at that time it was a little late for the city council to make a submission. I think the deadline is we may put in our submission in writing by September 14.

Further to that, I've just returned from attending the AMO meeting in Toronto, and I felt personally that was one of the biggest things on the horizon right now for this coming three years. It wasn't even mentioned. I asked about it, and they said, "Well, maybe there is a committee at AMO doing a study on it." "But," I said, "did you realize you have to get your submissions in by September 14?"

The Vice-Chair: Actually, the Association of Municipalities of Ontario made a presentation to the committee. I believe it was yesterday morning. We can get a copy of that for you if you'd like to have it.

Mrs Lee: I feel very happy that they have done that.

The Vice-Chair: Then you could go through it and write regarding that if you wish to. But we will get you a copy of that if you'd like to have it.

Mrs Lee: Yes, but each municipality may still send in its submission, right?

The Vice-Chair: Yes.

Mr Wessenger: Of course, anybody can send in a submission.

Mrs Lee: Because our concern in our municipality is the funding. In the legislation it states it'll be funded, but it didn't say who or how much and when.

The Vice-Chair: The municipality, and I know it is a member of the association, should be getting a copy of the association's response, because that's the normal procedure, to send copies of responses on all matters to member municipalities.

Mrs Lee: Well, my other question was, then the city council should have received a copy of Bill 173, am I not correct? Do they not send this out to all city councils?

The Vice-Chair: Many municipalities do get copies of all -- they apply and get the bills services of the provincial Legislature, which would ensure them copies of all bills as they come forward. But I don't think they would get it automatically if they're not a member of the bills services of the Legislature. So it is available, if you wish it, through that system.

The other thing is that of course the committee did advertise. The clerk of the committee did advertise the hearings, inviting representations, and that I believe is inserted in all daily newspapers, is it, across the province? So it would have been in the Chatham paper.

Mrs Lee: But because of the funding fact, municipalities should be very much concerned.

The Vice-Chair: Yes, and the association did make, as I understand it, a lengthy presentation, and we'll get you a copy of that if you would like.

Mrs Lee: Thank you. Now, I just have one other comment, and that is, I hope that you won't be recommending to close down too many beds, because I'm a health services professional. I've been at it for 25 years. I still look after a lot of seniors, and the seniors who are needing help now are needing more and more total care. It's practically impossible to send an 80-year-old semi-stroke home to be looked after on home care by an 80-year-old spouse. I just want you people to consider that before you make your vote.

I have even been brave enough to say that before people make these rules and regulations, each and every one of you should take one of these people home and look after them for a week before you come back and make the decision, because I'm very concerned that home care is not the be-all, the answer to everything, and it is not better care than some institutional care that's going to be needed, because one of the things is, big people are big, and in the hospital you can get two or three people to help you lift, turn and change them, whereas at home you're the only person and it's nearly impossible. Thank you very much for giving me this opportunity.

The Vice-Chair: A very serious concern; thank you for expressing it. Thank you for your presentation.

Mrs O'Neill: Mr Chairman, as the next group comes forward, I'm going to repeat now for the third time my request. This group brought it forward and other groups have brought it forward today. I think we have to clarify the implementation of the capping.

Now, we're being told that there's going to be an answer to this brief and we're going to be given a copy of it. I'm sorry; I'm not willing to wait for that. I feel now that the question of the appeal board and its membership has come up several times, and several times today. I'm making a further request now that we know who is going to make up the appeal board and I think this committee should get that information very soon.

The Vice-Chair: Could we just table that for the present time? The next presenter has a very serious problem with meeting a transportation deadline, as I understand.


The Vice-Chair: The next presentation is made by the representative of Persons United for Self-Help Southwestern Region. Please introduce yourself and proceed.

Ms Myrtle Evans: I'm Myrtle Evans, by the way, and I am vice-chair for Persons United for Self-Help. Now, I must admit I've learned a good deal today.

Persons United for Self-Help Southwestern Region -- we call ourselves PUSH, by the way -- have been consistently present at discussions surrounding long-term care. We have come to the table every time LTC -- which is long-term care, I understand -- has been raised. We stay involved at all levels of discussion because we believe that adults with disabilities have historically been insulted, then omitted, overlooked or ignored in governmental action planning. We are determined to ensure that long-term care, in this case Bill 173, will genuinely address our issues and concerns.

It is unfortunate that this Long-Term Care Act, 1994, Bill 173, has slipped so easily back into the errant ways we believed had changed. However, until such change becomes truly evident, our support for these initiatives will be withheld. Adults with disabilities have a reason to be concerned when they see years of working with government set aside on marginal input, but that is what Bill 173 has done.

Definitions: The absence of a definition of an individual within the bill says more about its intent than do all the other words strung together. This is particularly relevant in light of the recent announcement of the district funding program. The district funding program, one accommodating the individual, will not be functional without the appropriate wording included within the act.

We recommend the inclusion of the following definitions:

-- Individual: one person, one specific set of circumstances, personalized;

-- Direct funding: program supplying attendant service dollars to an individual to coordinate, account for and report on their own service.

As for the bill of rights, we respect this initial step in addressing the concerns of service users within the support service system. However, there are inconsistencies in the document which displace the intent of these rights. Examples of the problems herein lie in:

(a) The qualifications for being approved agencies, district health councils, committee of chairs, multiservice agencies, review boards or others. Nowhere is representation by consumers mentioned. The criteria cited call for "...persons experienced in the health services field...." This clearly prohibits participation by most disabled consumers.

(b) The fact that an MSA must meet four service delivery criteria. These are community support, homemaking, personal support and professional.


(c) Ratios of membership for cited categories have been omitted as well.

(d) There is no longer an acknowledgement of the value of consumer representation and participation at this level. Only those who profit from their systems' enrichment are included.

Accountability: Once appointed, by the minister or each other, the approved agencies, district health councils, committee of chairs, multiservice agencies, review boards and others are accountable to only the minister or each other. There are no provisions for being answerable to the geographic area. The local representation promised long ago is no longer evident.

Bill 173 then proceeds to renounce ministry, approved agency and service provider responsibilities for any future problems or injuries by stating that consumers must accept that providers are acting "with good intent." This is a prime example of governance in full abdication. It is an open-eyed endorsement of irresponsibility and omission. In the access to information criteria, consumers could be denied access to their medical records by service providers. This denial can be appealed to the Consent and Capacity Review Board, which may or may not uphold the original denial. This clearly violates an individual's human rights. Further, should the service provider present a medical affidavit stating the complainant is medically incapable of attending the review, the affidavit will be accepted at face value.

This provision is paternalistic. At no time should the consumer be absent from such reviews. Indeed, we charge the minister with the responsibility of establishing an extraordinary-measures clause which would necessitate a review postponement until the consumer is able to participate, or to go one step further and provide the required support to permit the consumer to participate. Should the denial-of-access decision be reversed, the consumer should then be provided the full information in the format they utilize best. I presume that's Braille, loop system or whatever you want.

Another unreasonable expectation is that unregulated waiting lists are still being endorsed as a method of addressing limited service availability. There is no purpose for approved agencies to assess client -- consumer -- requirements or assess eligibility for service when there are no services available for the consumer. This service screening formula is predicated on the nuance of a needs-based assignment, yet in reality assessments work from the-least-needful-get-service criterion. The incompatibility of the two methods results in consumer mistrust and frustration with the waiting list juggling act, which will not be dissipated with Bill 173.

Appeal avenues: It should be noted that ultimately ineligibility, non-availability, limitations or termination of service may be appealed to the Health Services Appeal Board. Yet there are no preliminary steps established to provide a more expeditious remedy. Further, the Health Services Appeal Board is already experiencing a minimum of a one-year backlog of complaints and will not provide a reasonable remedy for consumers who are in desperate need now.

Quality assurance: It used to take a simple telephone call to MCSS to resolve the glitches we experienced with attendant service. Then we were shifted to a long-term care area office and Gail Ure answered our questions. Now we're in a befuddled mess, with no one who will identifiably understand our services or be capable of responding to us.

We know this is not quality assurance, but we don't know what is. We cannot find a person in the milieu who is accountable for our concerns. We would like to know, what are the quality assurance standards, who is responsible for them and what are the evaluative techniques and implications?

These absences of consumer representation and choice, as well as the absence of accountability, appeal avenues and quality assurance guidelines discussed in the legislation raise more questions when one considers that we will be captive to the long-term care system.

Conclusion: Consumers are now raising more long-time -- the tongue's all right; the head's got to go -- long-term care questions than ever before. Their concerns are based upon the fickleness of a government that cannot decide whether adults with disabilities will be included in the hierarchy of decision-making or not. The multiple levels of systems bureaucracy outlined in Bill 173 indicate that disability-related services will be lost quickly in the morass.

Promises of participatory status for disabled persons has proven illusionary. Application to Thames Valley District Health Council by PUSH Southwest members has been fruitless. Indeed, we have all been advised that we don't make the infamous short list for interview consideration. Ministry of Health promises do not match our reality.

Perhaps the time is right for the Ministry of Health to acknowledge its deficiencies, particularly with disability issues and programs. We recommend that long-term care services for the disabled be returned, with the appropriate dollar assignment, to the Ministry of Community and Social Services. Ministry of Community and Social Services offices have always been effectual and responsive to our needs.

Unlike hospitals, nursing homes, homes for the aged and other institutions, we are a small but specifically needful population. We require responsiveness that can no longer be found in Health's growing layers of "expert" bureaucracy. We must be allowed to return our basic services to the ministry which served our needs best, the Ministry of Community and Social Services.

The Chair: Thank you for your presentation. Do you have time for a question?

Ms Evans: A couple. I'm not sure I'll be able to do them. I'm going to call Steve if I need him.

Mr Malkowski: Thank you for your presentation. Just to make sure I understand you correctly before I ask for clarification from counsel, were you saying that what you would like within the legislation is a guarantee for consumers specifically that people with disabilities are involved in the decision-making process and that in fact diversity is recognized within the legislation? Is that what you're looking for?

Ms Evans: Yes. I really think what we have to have is, the consumer has got to be recognized and involved, because nobody understands a person's needs like that person themselves. It takes someone in a similar circumstance to even, shall we say, interpret what the other person maybe needs or wants, because we've got an awful lot of people who -- in the last 10 years, personally I didn't understand a lot of people's needs, and I've been in a wheelchair for 40 years. But there are oodles of things I don't know anything about, because long-term care was not something I've ever used. I've been appalled at what they have been stuck with, their time schedules and a lot of things.

It's necessary, but I don't think people who are able-bodied understand that these people are so tied up. Like I am tied up right now because I've got to get a time schedule for my booking for Paratransit. Somebody else has got a time schedule; they've got to get Paratransit, they've got to get to support care, and if Paratransit's late, support care isn't there. It's pretty rough on them.

I want to thank you. If there are any more, I'll take one more.

Mr Malkowski: If I can just ask counsel for clarification on the nomination process, one of the concerns was, for example, that people have not been able to get involved in the process although they have tried to get nominated. What exactly is the process and could you clarify that for us?

Mr Wessenger: I'll just ask the counsel to go ahead.

Ms Czukar: I'll just be quick, if I can. What the bill provides for is that the minister, when designating an MSA, must consider the proposed board composition. She has to consider whether the board of directors reflects the diversity of persons to be served, according to certain factors, and disability is certainly one of the factors, and the minister has committed herself to wanting to see at least a third of the board being consumers.


The legislation doesn't use the word "consumers." What we have here, we believe, is a working definition of consumer, but if people want to see the word "consumer" there, maybe we can find a way to put it there and have that definition.

The other thing I would say is that the requirement with respect to a plan of service, participating in assessment and determination of need and that sort of thing in section 20, also requires the agency to give the person the opportunity to participate in developing the plan of service, plus they can name someone else to participate with them. So your point about sort of moral support in the process is a good one and is accommodated by that provision as well.

Ms Evans: I think that answers our questions.

The Vice-Chair: Thank you for the presentation.


Mr Don McDermott: Mr Chairman and members of the social development committee, my name is Don McDermott. I'm the administrator of St Joseph's Health Centre in Sarnia. With me today is Mr Philip Hassen, president of St Joseph's Health Centre in London.

We are here to represent our institutions, to encourage reconsideration of certain areas of Bill 173. Thank you for this opportunity.

St Joseph's Health Centre, Sarnia, is an accredited 317-bed community-based Catholic health care facility owned and operated by St Joseph's Health Services Association of Sarnia Inc. St Joseph's offers a range of health services to the residents of Lambton county which encompass the pre-birth to death experiences. These family-oriented services and programs both complement the roles of other health care organizations in the county of Lambton and as well make their own contribution.

St Joseph's Health Centre, Sarnia, provides active treatment services in general medicine, intensive care and surgery. We also provide the specialized regional programs and services of obstetrics, long-term care, rehabilitation, palliation and sexual assault treatment. A variety of urgent care needs are met in our emergency department, and through ambulatory care we provide outpatient diagnostic and treatment services. Specialty clinics and facilities complement our inpatient services and assist people to live independently in the community.

St Joseph's Health Centre, London, provides an unique continuum of care to the very young through to the most senior in the community, encompassing acute, residential, extended and long-term care services. An accredited Catholic teaching facility, it is affiliated with the University of Western Ontario and Fanshawe College. The health centre is owned and operated by St Joseph's Health Services Association of London, Inc, whose members of the corporation are certain Sisters of St Joseph.

The corporation consists of St Joseph's Hospital for acute care, St Mary's Hospital for chronic and rehabilitative care, Marian Villa for extended and residential care, the Lawson Research Institute and various programs located within the community.

The major program thrusts of the health centre include perinatology, gerontology, endocrinology and metabolism, gastroenterology surgery, hand and upper limb orthopaedic plastic services. Within gerontology, multidisciplinary programs include long-term care units and ambulatory consulting clinics. St Joseph's Health Centre is a partner in the regional geriatric program, which includes an acute assessment unit and outreach teams. The health centre is a partner in the Centre for Activity and Ageing, in a cooperative venture with the University of Western Ontario.

As a provider of hospital-based health services in Lambton and Middlesex counties, as well as southwestern Ontario, we support the goals of long-term care reform and the purpose of this act as stated in part I of the legislation, and we are pleased to appear today on behalf of the boards of St Joseph's Health Centre, Sarnia and London.

We share the Ontario government's concerns for integration of long-term care health and social services, improved access, community-based care where possible, consumer participation, racial equity, cultural sensitivity and spiritual recognition, funding equity across the province and protecting our staff. We agree with our affiliative bodies, the Ontario Hospital Association and the Catholic Health Association of Ontario, who have voiced the need to simplify access and coordinate services within the long-term care sector.

Of concern, however, are the implications of this legislation that could decrease consumer choice if services are limited to only those offered through MSAs in a particular area; diminish voluntarism and fund-raising if MSAs are divorced from agencies currently providing care in the community; decrease involvement of hospitals in the continuum of health care and the potential displacement of staff who currently provide these services; and the appended district health council roles that appear out of place in this legislation.

Our presentation today is an attempt to give Bill 173 a positive impact on health services in Ontario, building existing systems and linkages of providers into a continuum of care. Our first concern is a lack of consumer choice. Consumers will have considerably less choice under MSAs than they do now and will have difficulty being accommodated with their first-choice placement. Indeed, a person may in fact wish placement within an institution for reasons such as the religious nature of the provider but be unable to have it because of the nature of the MSA. As described in part III, the bill of rights, paragraph 3(1)3, spiritual consideration must be a component of placement selection for services. This will be difficult to operationalize within this legislation.

There are many charitable non-profit providers, both religious and otherwise, who will not become part of an MSA because of the limitations the restructured MSA governing bodies would impose. Often these providers are of a specific spiritual or cultural mission. Elimination of these choices, as would occur under the proposed Bill 173, would not allow the consumer the choice of cultural sensitivity or spiritual considerations as described in the bill of rights or as is currently available.

The identify of many organizations will be lost, but even more importantly, established standards, efficient operations and functional teams of health professionals trusted by the community as representing certain values will disappear.

We therefore recommend that the spiritual consideration, as a consumer choice of services provided by MSAs, not be lost in the effectiveness of the legislation.

Our second concern has to do with the loss of identity and its consequences. The perception of an MSA is one of government bureaucracy in consolidating the services of current provider agencies. People give to agencies to which they feel ownership, affiliation or need. A government agency will not have an identity to which people will give either time or money.

The potential loss of culture and history should not be ignored as this bill proceeds. Surely a current provider can be incorporated into an MSA through affiliation rather than absorption. The opportunity for multiple MSAs in one region is present in the bill, part VI, subsection 2(4). This affiliation would strengthen the voluntarism and potential fund-raising capabilities of an MSA while building on the identity and expertise of current providers.


The opportunity for affiliation should be explored before legislating absorption of agencies which provide value-added programs through their diverse and independent governance structures, religious affiliation and quality programming.

We therefore recommend that planning for MSAs in each area include the opportunity for affiliation agreements and multiple MSAs, rather than limiting models to absorption of existing agencies within one MSA.

Our third concern is decreased recognition of institutions as part of the continuum and the potential displacement of current service staff. Many institutions currently provide services to clients in their home and in a group setting. The 20% maximum cap on MSAs' purchased services will eliminate many current providers and potentially shift the service to an MSA without shifting the care giver.

Existing expertise and provider-consumer relationships should be maintained and built upon wherever possible, with special recognition given to ensuring the 20% purchase cap does not displace health workers who already provide this care. The 20% maximum for purchased services seems arbitrary and should be left to the individual region for the right combination of provided and purchased services, be they for-profit or non-profit.

Should it be determined that a service is best provided by staff of an MSA rather than a purchased service, the staff of the current provider should be given the opportunity to relocate to the MSA before the MSA hires another staff person. This will prevent significant displacement of workers across the province.

Institutions can play a leadership role in this human resource planning and transition if the other players are willing. In ensuring that a wide range of community-based services are available in the home as an alternative to institutions, the legislation fails to understand the valuable role institutions currently play in adult day programs, specialty clinics, information resources, training, professional and support services, palliative care and respite care. Institutions should not be considered an alternative to community care, but rather a partner in a continuum of care that will see clients using various institutional and community-based services at different times as their needs require.

MSAs should be structured to ensure that this partnership with institutions continues in community service provision and planning in an efficient and economic manner, through single access.

We therefore recommend, first, that the 20% maximum on purchased services be removed and that each region plan its own ways of providing efficient and effective services through its MSA model; second, that a human resources plan for MSAs give consideration to all existing providers for staffing needs before new hiring takes place, and institutions need to be a player in formulating this plan; third, institutions be considered and included as full partners in a continuum of health care and not seen as alternatives to community-based care.

Our fourth concern has to do with district health councils. The inclusion of amendments to the Ministry of Health Act in subsection 62(1) to enshrine district health councils' governance and functions deserves special legislation rather than what appears to be a disjointed or last-minute approach by adding their role to a long-term care bill.

This process is doubly confusing in that the Lawson report, the final report of the regional planning steering committee for southwestern Ontario, tabled June 1994, appears to recommend another layer of planning bureaucracy above the district health councils, with similar duties but without stakeholder consultation. These regional health councils need review before district health councils' roles are enshrined in legislation so that everyone's responsibilities are clear.

We therefore recommend that district health councils be given individual legislation that is well thought out and clear in its relationship to regional health councils, as defined in the Lawson report, and the Ministry of Health.

In summary, we are pleased that action is being taken to lead a process of integration and improved access to the long-term care health and social service areas. We question the legislation in reducing the consideration of choice, especially of a cultural and spiritual nature; the use of absorption rather than affiliation tactics; limiting MSA purchased-service options, and we reinforce the need to consider a human resources plan. We also request that health institutions be seen as partners in this process, and we question the reason for district health council legislation in this act.

Thank you for the opportunity to present before this committee.

Mrs Caplan: Thank you for an excellent presentation. The question that I have relates to the areas that you've selected. We've heard a lot about the consumer choice, so I'm not going to question you further on that because I think that's clear. But what I am interested in is your view of the ability to purchase services above the 20% maximum that this legislation allows.

I'll start out by saying that I share the concern that you have, but I'm interested in what your experience has been as an institution that's looking at efficient ways of delivering service and whether you know of other institutions that are out sourcing services and whether they have had any experience around cost-savings as they relate to purchase of service from the private sector? Do you know what the institutional experience is?

Mr McDermott: We provide a number of outpatient services and in-community services through various agencies. Often this is done because some of the professionals are located within our institution and are often not available to the community agencies in any other way. Of real concern to us is that, should the MSAs be structured as within this legislation, first of all, institutions would then be separated from the MSA process. Second, the professionals who work for us would not have an opportunity necessarily to become part of that MSA process. Both of those are failings of this legislation and don't take into account the opportunity for the professional or the institution to be part of the process.

Mrs Caplan: Do you feel that could be accomplished simply by the elimination of the 20% maximum? Would that ease your concern about that, or do you feel there's another part of the legislation that would require amendment to ensure the continuum and the partnership between the institutional and the community-based care requirements of the patient or client?

Mr McDermott: I'll answer the first part. The 20% is limiting, I think. It really limits the opportunity to negotiate and to work together within a region or community. The second part, I think that institutions are not really addressed within this legislation, and if you look at acute care reform across the province, really excellent things are happening within institutions and among institutions. I think there's opportunity within community agencies to do very similar, positive rather than negative voluntary activity.

Mrs Caplan: I like the language that you used on page 7 when you say that each region should be permitted to "plan its own ways of providing for efficient and effective services through the MSA model," and I'm aware of the concern that you have about the mandate given to the DHCs. Where do you see that regional planning taking place?

Mr Phil Hassen: Maybe I can just add a couple of points to those that Don has already addressed. I do think that we need regional planning. There's no question as we go through these transitions, and there needs to be though a final source of decision-making on some of the issues. The problem is that they never seem to get done at the level they need to be done. They seem to keep wandering through, up the government levels. I won't belabour it, but we just had a document we needed to get done -- and, Mrs Caplan, I think you remember the St Mary's project. We are now getting the tunnel and it took 13 signatures to get that done, just to get a little piece done.

Our question is, who's deciding these things and what are the objectives that you have in health care reform? It seems to us a systems approach needs to be taken in an integrated way within communities, not in what are seemingly traditional stove-pipe agendas to protect certain turfs, whether it's hospitals or whether it's communities or whether it's district health councils. The integration has to occur and it must occur at the local level.

The question that needs to be answered is whether you're prepared to let the local communities, with some parameters and final decision-making, make it happen. I think there will be some differences, but there can still be policies explicit by government to guide that.


Mrs Caplan: That's why my question is -- I don't want to use any specific term. What table do you see that happening at? I'm familiar with the fact that there are a number of proposed alternatives for this particular area, but if it's not the DHC, and you're concerned about a regional DHC, and it can't be the hospitals by themselves, where do you suggest that regional planning take place?

Mr Hassen: I wouldn't exclude the DHCs, but I think they need to be reformatted. For example, for London, because of the complexity of its serving southwestern Ontario, there needs to be a body that incorporates the needs of those people and the sensitivities to it, and thus legislation must contemplate those requirements. It cannot be done, again, just for London.

While I think London's DHC has been very sensitive to that issue, there are still issues arising that go beyond and the complexity of planning is so large, I think it needs a table that is of that nature. But I do think you need one kind of body that says, "We will make the final decisions on these things at our level." It doesn't have to go to government if it's within the mandate of the parameters established by government, or the policies, but unfortunately the policies never seen to be quite clear. I think we need to clarify those so that people at the local level can make those decisions.

The Chair: Thank you both. I know we could continue this, but I regret again time is our enemy. Thank you for coming and for your presentation.


The Chair: If I could then call the Thames Valley District Health Council and long-term care planning committee. Members will note there are two presentations -- how I can put it? -- two presentations with this submission. Does that cover it?

Ms Kathryn Bamford: Yes, that's correct, actually.

The Chair: Okay. I think I'm in your hands. If you would like to present both of them, that might be the best way and then we'd move to the questions, but we thank you. We recognize a few faces but recognize as well that people play a variety of different roles. Welcome to the committee and please go ahead.

Ms Bamford: Thank you very much. I was going to say my sister was here this morning, but you've obviously taken the wind out of my sail, so to speak.

First, I'd like to present not only for the Thames Valley District Health Council, of which I'm chair, but also for the District Health Councils of Southwestern Ontario. We've gotten together and put together a collaborative presentation. That will be the first part of our presentation.

The second part will be specific to our long-term care committee of the Thames Valley District Health Council. I'll briefly go over some of the points that are in the presentation there as well.

As you know from this morning, my name is Kathryn Bamford and I'm a three-year volunteer with the district health council. I'm past chair of the long-term care committee and present chair of council. I'm also past chair of the Oxford Senior Services Advisory Council and the executive director of VON Oxford. I'm a Woodstock resident. I'm a consumer and a mother of two teenagers.

The Chair: Many hats.

Ms Bamford: Many, many hats, so you're hearing this from many perspectives. I suppose I became extremely interested in district health councils from all those various perspectives and trying to find answers, to find out why and what can be done about the system the way it is now.

The District Health Councils of Southwestern Ontario value the opportunity to respond to Bill 173. This response will focus on the act's reference specifically to the district health councils. Additionally, the six health councils within the southwest planning region have prepared individual responses specific to long-term care contained in Bill 173.

I'll just talk a little bit about district health councils for those people who are unfamiliar with the concept. We were created in 1973 under the Ministry of Health Act, which stated that, "The Lieutenant Governor in Council or the minister may appoint committees to perform special advisory functions as are considered necessary or desirable in order to assist the minister in the discharge of his or her duties," and, "Subject to the approval of the Lieutenant Governor in Council, the minister may make regulations...requiring and providing for the approval by the minister of regional and district councils for planning health and hospital services and their structure, functions and duties."

In the southwest region, six district health councils are established by order in council, including the Essex District Health Council, Grey-Bruce, Kent county, Lambton, Thames Valley and, most recently, Huron-Perth.

Additionally, the five health councils existing in the southwest in 1990 established an informal structure called the District Health Councils of Southwestern Ontario, the reason being to collaboratively address cross-district health planning issues. In 1993, the Huron-Perth steering committee, before it had a DHC, joined this body and started to collaborate with us on different issues.

All members, such as myself, of the district health council, excepting the staff, are volunteers and volunteer their time regularly and frequently to plan system responses to the community health needs. We see our purpose as trying to integrate the different aspects of our planning committees. These members are pleased that after a 20-year history of providing the citizens of their districts and the government with valuable health care planning advice, the government is now prepared to formally recognize our important work through this proposed legislation. This not only provides recognition but, also importantly, conveys the credibility and legitimacy of our role to the health care provider and consumer communities.

I'll just talk a little bit about the amendments, and it's really contained to pages 47 and 48 of the act, where we talk about the specifics to the district health council. We've added comments in addition to what the act outlays.

Councils suggest that subsection 8.1(1), which refers to areas not included in the DHC and the geography, may be redundant since now all geographic areas of the province and all non-aboriginal populations are represented by district health councils following the establishment of the Huron-Perth District Health Council.

With subsection 8.1(2), regarding members, the councils agree with the role of the Lieutenant Governor in Council or the minister in appointing council members. Councils do, however, stress the need for the appointment process to proceed in a timely manner.

At present, we have five openings, for instance, in the Thames Valley District Health Council and nominations have gone forward. But we may operate for almost six months without those five members, which leaves the rest of us having to really do double duties, so it really does burden the members who are presently there. We would ask that this process be improved.

In subsection 8.1(3), again councils agree with the role of the Lieutenant Governor in Council or the minister in ensuring that the membership of the district health council reflects the diversity of the population in the council's geographic area. Notwithstanding the above, councils stress that appointments be made based on skills and experience and not on any particular group representation other than gender or geographic, since at no time is it possible for a council to have all interested groups represented on this membership.

You may very well be aware of two position papers which have been presented to the ministry, one regarding a labour issue and one regarding OMA and wanting representation on health councils. I think it needs to be emphasized that their input is extremely valuable and can be acquired through professional bodies or other affiliated organizations, but to have actual representation specific to that group is very difficult to deal with at the council table.

Clause 8.1(4)(a), regarding functions: Councils agree with the stated function of advising the minister on health needs and other health matters in the council's geographic area but stress that in doing so, councils are responding to both the policies of the ministry and the uniqueness of their local districts and communities. I think we feel very much a dual accountability, both with the ministry's policies and directions as well as the communities in which we live.

Clause 8.1(5)(a): Councils accept the right of the minister to direct them not to exercise one or more of their functions with respect to the aboriginal community, but ask that the proposed legislation be revised to ensure that any health care planning conducted by aboriginal groups is shared with the relevant health council, since the providers of health care for these populations are usually existing providers who serve other, non-aboriginal populations and that recommended changes to delivery of services must not be acted upon without the district health council's assessment of its impact on the district's broader health system. I think again this illustrates the point of how interdependent the system is and how important it is that we communicate with each other, because there tends to be a domino effect that we are in fact planning with the people in their best interests.

Subsection 8.1(6): This section is most relevant to the current policy of the ministry which requires all hospitals to submit yearly operating plans to the district health councils. Extending this role for district health councils, such that all health care providers are now required to submit these operating plans, must be considered within the context of the need for additional health resources for the councils to objectively and fairly review these plans in detail, deserving of the role. What we have seen this to be is an added responsibility which again assists us with this integration and congruence within the health care system. But again the problem is the strain of limited resources and the strain of limited volunteers to actually do the work.


Clause 12(d): Councils agree that the role of the ministry vis-à-vis district health councils is to govern them, but the term "govern" is not consistent with the term "manner of operation." Councils expect to be able to interpret the ministry's governing policy within the context of the local need. If council, for example, believes that it doesn't require an executive committee, then it should not be required by the ministry. This type of micromanagement by the ministry can discourage innovative thought by council members at a time when such creativity is needed. The governing role of the ministry should be one of stating ends and identifying means only to the point where any reasonable interpretation of those means by councils can be accepted by the ministry.

Clause 12(d.1): The stated role of the ministry in governing the recruitment and selection of members of committees, or of any class of committees, of a district health council is again interpreted by councils as possibly overstepping the intended bounds of governance. Committees are committees of councils, not committees of the ministry, and such are the council's means of achieving the ministry's ends. If the ministry controls this level of means, it again risks stifling creative approaches across the district health council system.

An example of that: We have presently seven committees of council. The long-term care committee has many, many subcommittees and we're totally engaging, on a regular basis, 212 volunteers -- we just did a head count before I came -- on that one subcommittee of council alone.

The six district health councils in southwestern Ontario are encouraged by the scope of Bill 173. The suggested revisions to the sections referring to the district health councils are represented by those with significant experience in serving their Minister of Health, the ministry and, most importantly, the communities and individuals within those communities. Hopefully, they will be reviewed in the constructive manner in which we presented them today and in which they are intended. Thank you.

I have Paul Huras, the executive director of the Thames Valley District Health Council, to help me with questions in this regard.

The Chair: Okay. Should we do the long-term care planning committee presentation as well and then we can question on both?

Ms Bamford: Sure. How much time do we have?

The Chair: We have time for you to do that and then for questions, because I know you will do it expeditiously.

Ms Bamford: I wasn't planning to read the whole thing, but maybe I can just speak to a few items.

I had the privilege of chairing this committee for two years and I'm now past chair. Marian Millman is the chair. With me is Judi Fisher, who's a member of that committee. We have three council members on that committee. There are 22 members and we wrestled with this whole issue of representation and interests to be somehow represented at the table and we worked through that. You'll see that there are some fairly significant suggestions and comments about the act, and I won't go through all of those.

I'd like to move on, if I could, to a couple of the issues that are of most import and one is item number 14. I didn't hear, this morning when I was here, how this was addressed. Item number 14, page 3, speaks to children's services and long-term care. I don't know if you're aware, but the ministry of Community and Social Services is now undergoing a restructuring exercise. I've just received a fairly lengthy survey asking for input on what restructuring means and how all that happens.

I'm wondering where these children fall. Many of them fall between the cracks of the Ministry of Community and Social Services and the Ministry of Health, and again, the long-term care committee has put together its concerns, asking, where do these children fall in the act? Services to children who are medically fragile and who have high care needs and to their families who require nursing and therapy services should be included under the basket of mandatory core services. They need to be included. They tend to fall between the cracks. These are people who have had to label their children, so to speak, to fit the funding envelopes that have been available in the past. So this really needs to be addressed.

It's important that the core nursing and therapy services in the MSA provide nursing and therapy services to children, wherever they may be, including day nurseries. Right now, there is an exclusion in day nurseries that children are not able to get the service, which burdens parents tremendously. If we look at that whole continuum of care and keeping those families well to maintain those children throughout their life expectancy, through their lifespan, and give them some quality of life, then we need to care for those parents and care givers as well. We hope that if it's not the intention of the core programs to provide nursing and therapy services in day nurseries, it be reversed as soon as possible, as stated in the legislation.

The other thing I just wanted to reiterate, and it was spoken about this morning -- a gentleman, a consumer, spoke to it -- was the appeals process. The long-term care committee felt very strongly about this. They certainly agree with an appeals process but would like to see the following included in the regulations for the process. The process should be independent of the MSA and there should be local appeal boards, which make the decision, linked to the intended provincial board. It is important that these boards be located at the local level for expeditious response, and that reiterates what this gentleman said this morning.

The boards should be able to be put in place and respond quickly, and we suggest that the provincial and local appeals board comprise 50% consumers and 50% others, defined as non-ministry-funded agencies, member representatives of education, local businesses, local church groups, to ensure objectivity and an arm's-length approach. Those are really the two most salient points, I think, in this presentation.

The Chair: Fine. Thank you. Can I express my ignorance? You may have said this, but if not, I may be joined by other members at the table. The Thames Valley District Health Council then covers Middlesex --

Ms Bamford: Elgin.

The Chair: Oxford?

Ms Bamford: Oxford.

Mr Eddy: London and St Thomas.

Ms Bamford: Yes, London.

The Chair: Thank you. I knew one member of the committee would know all of that. Mr Eddy knows this.

Ms Bamford: Yes.

The Chair: Okay. Thank you. I just wanted to be clear on that. We thank you for both of those, and I know that a number of the other issues that are raised in the long-term care committee's presentations are ones, certainly, that we've seen before, but we have them here on paper.

Mrs Cunningham: This is the second presentation today by a district health council, but obviously you've gotten together with regard to the first one, so that's great.

I noticed that underlining the concerns of, I guess, all three presentations, but especially the latter one and the one from Kent, was the appeal board. I'm underlining them as they appear. Also, you didn't talk about the cap, I don't think, the 20% --

Ms Bamford: No.

Mrs Cunningham: -- and the problem in choice in that regard. I wondered what your opinion on that would be. Also, with regard to defining the individual, you talked about that, and I'm happy that you noted the representation of the consumer on these boards and then of course the makeup of the appeal board.

I wondered if you did want to talk about the cap, and also, as a number of district health councils, have all of you considered different agencies that may qualify within their own geographical area as the considered agency, under the act, for the provision of the services?

Ms Bamford: Okay, so the first question you have, Dianne, is with respect to the capping, the 20%?

Mrs Cunningham: Yes, I'd like to know your opinion on the capping because it seems to come up everywhere.

Ms Bamford: It does seem to come up. I'm probably a bad one to ask that. I will pass this over to Judi Fisher, who is the member of the committee that also generated the discussion paper which you may have seen in January -- not Judi alone. Certainly, there was a committee struck at the time I was chair of council that put together that discussion paper. Again, that's what it was, to generate discussion, and it was presented at a long-term care conference in January. I think I saw some of you there. It addressed, actually, our collective thoughts that certainly are representative of many of the consumers at the table of the long-term care committee. But I'll pass it to Judi to speak to, because it would be an update from that actual discussion paper.

Ms Judi Fisher: I should say thanks, eh?

Ms Bamford: Yes, right.

Ms Fisher: Actually, we did make a comment, on page 2 of our presentation, on the limits of service, but the reference is more in terms of the flexibility. Those were comments by some of the members of our committee who are home care managers, in terms of flexibility.

We didn't specifically make a comment on the cap but we still have some concerns on the limiting to the 20% purchase of service. I don't think we actually put that in our presentation.


Mrs Cunningham: I commend you for the fact that you're talking about the inclusion of services to children. We're really looking for as much choice as we can get, and when we start looking at those kinds of numbers -- I'm only speaking on behalf of my own experiences, of course, and certainly others who have come before the committee.

With regard to my second question and how you would be considering the appropriate agency to be designated, do you support the legislation's bias specifically against the boards of health?

Ms Fisher: I think the comment that we made refers to the fact that we're glad that it's been left open to more than municipalities and boards of health. We've barely begun the planning process in terms of the multiservice agencies, and I think the way we're going is more initially looking at the parameters of what would be included within that multiservice agency before we get into looking at models, and we are struggling with that, so looking at the different components being the access and the service delivery, management and governance and looking at what we presently have and then how that can be changed and then what kind of a process in terms of proposals.

Mrs Cunningham: So when we looked at -- I think it was an appendix to the board of health's brief today, there was a presentation to the Thames Valley District Health Council. Therefore, we should assume that that's not a bias. You're just saying that you're pleased that the legislation has pointed out that there are agencies beyond the boards of health?

Ms Fisher: Paul, did you want to comment on that?

Mr Paul Huras: We haven't encouraged anyone to submit proposals, but proposals have been developed, and I think that's very appropriate for organizations to be looking at their future from a strategic approach. Some of them have decided that MSAs do fit with their mission and have developed proposals. We are accepting those proposals as information to help us in our determination of models and are advising people who do take it upon themselves to submit proposals, but we are not requesting proposals at this time. They may be very helpful to us in developing the type of model that would be appropriate for our community.

Ms Bamford: Just to add to Paul's comment, what we believe is that local communities should be doing planning with the assistance of the health council. So what we've done is we've established within each county a planning body, a long-term care committee, and each of those community planning bodies has subcommittees. It's a mass of volunteers, but that's how you ensure you get consumers, people. They don't have to go to London to plan for this. They can get help by their neighbours to go to the local church to meet to discuss how this long-term care system should look.

As Paul said, we're trying not to elicit proposals. This is not a competition; this is a collaboration. We're taking a community development approach. We're trying to get people working with each other to solve some of their own problems and to come to us with some solutions and some options as opposed to us saying: "This is the way it's got to be. This is the way that we're going to solve your problems." And we think it's working. It's very painful, it's very time-consuming, but I think it's worthwhile.

Mrs Cunningham: Mr Chairman, could I ask a supplementary to that?

The Chair: I'm afraid we are a little tight on time and perhaps you can ask that separately.

Mrs Cunningham: I think just that probably the concern here is that if the governance of the board of health can be changed, they would be considered, but I'm not even sure why they should have to do that. That's my point.

Why would we get into this? Aren't we looking for an agency that can represent the needs of all of these clients they serve and administer these services? Isn't that what we're looking at? They may differ across the province and I guess I object to the boards of health being in there.

Ms Bamford: We're looking at collaboration, and we're expecting not various proposals competing from one part; we're looking for people to come together and reach some consensus. So the board of health will be very much a part of that planning, I think, just as much as the hospitals should have input as well. But I think the comment made by the long-term care committee reflects that there are community agencies out there who have already a lot of expertise in providing this type of service, and I'll use home care as an example. We need to build on that. We need to build on what they already know rather than try to invent some new structure.

The Chair: Thank you all for coming for the two presentations.


The Chair: If I could then call on the Oxford, Middlesex, London, Elgin, St Thomas home care case managers. That's a large area to be covered. Members have a copy of the presentation. Welcome to the committee. We appreciate you coming this afternoon and if you'd be good enough to introduce yourselves and then please go ahead with your presentation.

Mrs Lynne Hammond: Thank you. I'm Lynne Hammond from Middlesex county. On my right is Susan Deffett from Elgin county and on my left is Doris Adams from Oxford county, and doing our graphics for us this afternoon will be Donna Jordan from Middlesex.

The case managers of Middlesex, Oxford and Elgin counties thank you for this opportunity to address the committee in response to Bill 173. In reviewing section 20 of the bill and watching the Toronto hearings, it has become apparent to us that the role of the case manager is not well understood. Bill 173 does not directly address the case manager. Therefore, to clarify our role, we wish to present the paper which was previously given to our local district health council.

Case management is one of the best-kept secrets of home care and is invisible to most people because of the nature of its role. Someone once said, "The art is concealing the art." We believe this applies to case management. Although case management is not always visible, it is a direct service as well as an integral part of the health care system, and will continue to be so.

We have chosen to compare a case manager's role with a client to a general contractor's role in building a house. They both work behind the scenes. Today, we will show you some examples of how a home care case manager builds a house. Later, we will show you a case manager of the future to build the house.

First, a brief background of case management. It has its roots in public health nursing and social work. It is considered to have begun in North America in 1863 when the Massachusetts Board of Charities established a case management program to coordinate public service and conserve public funds.

In southwestern Ontario, case management began in the mid-1960s as a pilot project when hospital liaisons started to plan services for patients discharged earlier than usual from hospitals. As home care expanded, the liaison title changed to coordinator and then to case manager, which reflected the increased responsibility of the position. Besides assessing clients for eligibility, case managers were to assist ineligible clients in finding alternate services. The role has continued to be refined because of changes in health care, yet its primary purpose remains the same as it was at its inception: to ensure that client needs are met in the most cost-effective manner.

To quote Kathy Desai, director of Oxford county home care and University of Western Ontario case management course instructor, "Whenever we as a society have wanted to balance quality and quantity, we have resurrected the case management model -- hence its popularity today."

Again, the case manager of home care has many functions analogous to those of a general contractor. The general contractor, in building a house, knows who can get which job done for the best price in the most timely manner, so that his customer is satisfied. The case manager, by assessing, planning, coordinating and implementing, builds a house that meets the health needs of a client. The case manager also knows who can get which job done for the best price in a timely manner.


The case manager builds a foundation with an assessment. The framework is then constructed with planning and coordinating of resources. The roof of the house ensures accountability.

We have chosen three vignettes requiring varying degrees of case management to demonstrate various aspects of our house-building.

Ms Doris Adams: Mrs W is a 72-year-old retired registered nurse who was widowed 10 years ago and has no other family. Although her eyesight has become progressively worse, on assessment, Mrs W related that the Canadian National Institute for the Blind had helped her to modify her kitchen. She was able to do her own meal preparation and laundry. She was also able to bathe independently. CNIB provided her with transportation to their weekly functions and to the doctor. Mrs W had privately hired someone to do the vacuuming and the dusting. She was requesting that home care assist with occasional mending, reading her mail to her and transportation. The case manager explained the eligibility criteria for home care and that Mrs W currently was not eligible. The case manager recognized Mrs W's needs, however, and made a referral to Friendship in Action, as well as to a volunteer student group at the high school. The case manager contacted a senior citizens' group to check on more volunteer transportation for Mrs W. Her record will be kept on file for future reference at home care. The case manager is accountable to see that funds are used appropriately and that client needs are addressed.

Miss D is a 28-year-old woman who had a car accident which resulted in a fractured hip, crushed heel and fractured elbow. After a lengthy hospital stay, she went to her mother's home to convalesce. Physiotherapy and occupational therapy were requested by the doctor at the hospital and assessed as appropriate by the hospital case manager. However, once home, initial reports from the therapists indicated that both were addressing the same problems. After discussion, the case manager asked one therapist to discharge to prevent duplication.

By maintaining a flexible plan of care that is client-specific and preventing duplication, the case manager ensures that needs are met in a cost-effective manner.

Our final vignette: Mr B is a 45-year-old man who has supranuclear palsy, a progressive neurological disorder. The request for home care assessment was made by the doctor after the family had phoned him with the need for care giver relief. Mr B was assessed in his home by the case manager. Problems identified were complete loss of voice, difficulty eating and swallowing, loss of weight, increasing fatigue, deterioration in motor and cognitive functions and signs of depression.

It was quickly clear to the case manager that the client required a speech pathologist to develop some method of communication. A nutritionist was required to address his weight loss and nutritional needs. Some of the activities the client was trying to complete were difficult and tiring for him. The case manager saw a need for an occupational therapist to review safety issues and how the client was functioning in his activities of daily living.

The case manager planned to provide a nurse to teach basic nursing care to the care giver and provide emotional support. A homemaker was required to provide care giver relief, as the wife was tiring and the client could no longer be left alone safely. The case manager set up a tentative plan of care with the family at the time of assessment and began long-range planning. The need for family relief and future placement options were discussed. The wife and two daughters were visibly relieved that help would be available. The doctor was then contacted by the case manager and the needs were discussed. The doctor appreciated the direction for care of his patient and services were initiated.

Through the assessment process which had originated from a simple request for help, the case manager identified the client's extensive needs and established a plan to meet those needs and thus improve his quality of life. Internal resources were identified as well, and the case manager worked to enable the client to utilize these effectively to promote independence. Maintaining independence in the community translates into decreased cost to the health care system and empowers the client and the family.

Ms Hammond: Our house, built with a foundation of assessment, a frame of planning and coordinating and a roof of accountability, ensures high-quality care delivered in a cost-effective manner with a human touch. The bricks covering our house are other skills and abilities of a case manager, including advocacy, flexibility, objectivity, listening skills, resourcefulness, interviewing skills, education, creativity and public relations.

We, as home care case managers, have reviewed our goals in line with directives given in the long-term care reform proposed. Who is better able to present a vision of case management reform within the proposed MSAs than the case managers? We have shown you our present houselike structure. The general contractor of the future will have a new approach to house-building because of changes in the economy and consumer demands for quality, and so must case managers. The house of the future shows our focus is now broader. This is demonstrated by changes in how the house will be built. For example, accountability joins assessment to form the foundation of the new house. A firm foundation of accountability in the new house provides the basis for building an innovative, flexible model of health services.

The case manager has always been accountable, yet the emphasis on it will be even greater in the future. With responsibility for assessments being shared with other professionals and the projected need for cost containment, accountability will need more emphasis. We place it, along with assessment, as part of the foundation of our new house. Case management of the future will continue to provide expertise and available resources, budget management and objectivity to other professionals involved with the clients.

We envision various levels of case management. Professor Carol Austin, a leading authority on case management, has described two levels of case management she terms "deep-dish" and "drive-by." Our example of drive-by style may be a client with a single professional service need to reduce duplication of assessments. The deep-dish style is for the vulnerable client, or the client with complex needs, such as the gentleman in our last vignette. Case management is a direct service to the deep-dish client, just as the nurse or therapist provides a direct service. The case manager would determine the appropriate level of case management for a given client.

Continuing with the construction, partnerships will replace and thus enhance coordination and planning as the framework of the house. The partnerships will be with clients and providers, to facilitate coordination and planning. Partnerships include shared responsibility and duties delegated to those who can achieve them in the most cost-effective manner. Partnerships focus on enabling and empowering clients in their decision-making and, ultimately, their own case management in some instances. A partnership approach lends itself to a model that is flexible, creative and innovative.

We have chosen quality as the roof for the new house. We envision case managers assuming a larger role in quality assurance. The roof of quality will be made up of an interagency quality management program spanning traditional boundaries and improving quality on a continuous basis. A continuous quality program will not succeed without incorporating the values and wants of the consumers of care. The case manager alone will not be able to attain quality in home health care.


University of Western Ontario researcher Dr Carol McWilliam describes a collaborative model, equally involving all agencies and all categories of participants, which will hold the only hope of implementing continuous quality improvement of in-home care. The case manager will contribute equally with all other partners in home health care to achieve the desired quality: an innovative, empowering, collaborative, continuous quality improvement partnership model.

The same bricks from our original model will be needed to construct our house of the future. The same skills and abilities will be required of the case manager of the future. We believe that by basing our foundation in accountability and assessment and by building on the foundation in partnerships, we can enhance the quality of life for residents of Middlesex, Oxford and Elgin counties. We therefore have put on a roof of quality.

Ruth Grier states: "Effectiveness means finding the treatment or program that produces the healthiest outcome. The quality of care we receive must be maintained at the high levels we expect and deserve." The district health council is the architect of our local MSAs. We leave you with our vision of the future.

Ms Susan Deffett: In summary, Bill 173 does not address case management. We believe that providing an independent case manager rather than assigning this role to one of the service providers will yield better and more cost-effective care in most cases. An objective, holistic assessment by a professional knowledgeable in community resources is essential. Expertise in assessment and resource management are distinctive qualities of present case managers.

Page 6 of the compendium, which addresses one-stop access through multiservice agencies, refers to a person who will take responsibility for providing accurate information, making appropriate referrals, assisting to identify needs assessment and determining eligibility, developing a plan of service with the consumer, arranging for workers to provide services, and monitoring and making necessary adjustments. We recommend this person be a professional case manager.

The Chair: Thank you very much for an innovative presentation. Ms Haslam.

Mrs Haslam: As a teacher, I appreciate the visual aids. It helps those of us --

The Chair: Especially at this point in the afternoon.

Mrs Haslam: Especially at 5:30 in the afternoon.

Thank you for your presentation. It certainly presents your case very well. It's interesting that you mentioned Kathy Desai, because earlier she had made a presentation. She talks about integration, allowing case managers to do the job with the consumer, which is where I'm coming from, to be sure the consumer has as much input and control and involvement in it as possible, but also looking at the efficiency and cost-effectiveness of the program. She mentions that integration is the key to the success. I wondered if you could elaborate on that a little bit, versus a brokerage system.

Ms Hammond: Unfortunately, I wasn't here for Kathy's address.

Ms Donna Jordan: I think when we talk about the two different levels of case management, it suggests some flexibility there. I think that's what Kathy is maybe thinking there with integrating the home care in a better way, that you don't always need as much case management in some cases; you're integrating by allowing the nurse or the therapist to oversee some simple cases rather than allowing a professional case manager to do the case management.

Mrs Haslam: So it's that seamless system that we are very interested in going to rather than having three different people follow through. Okay.

The Chair: Thank you very much. The other thought that occurred, where I think you've done some subliminal work on case managers, is that most of us think of "deep dish" in relation to pizza. We'll never be able to order another deep-dish pizza without saying "case manager," so it'll keep you in the forefront. Thank you very much for coming and for the joint presentation.


The Chair: I call the Canadian Red Cross Society, southwest region and Windsor branch. Welcome to the committee; it's nice to see you. I know you've been here listening to many of the other presentations. We're glad to have you with us. Please introduce yourselves and go ahead.

Ms Mary Kay Croft: If I had known, I'd have brought visual aids, but I have to tell you straight up we don't have any. My name is Mary Kay Croft and I'm regional director with the Red Cross homemaker service in southwestern Ontario. With me today are Walter Willms, who is the president of the branch council in Windsor for Red Cross, and Jim MacPherson, who is the regional director in southwestern Ontario.

On behalf of the Red Cross, I extend appreciation for the opportunity to share our thoughts and ideas around Bill 173. It is our intent to provide a brief summary of the report for you, and hopefully there will be time for questions and discussion. To do that, I'm going to talk fast.

The Canadian Red Cross Society is a non-profit charitable corporation incorporated under federal law. Canadian Red Cross Society, Ontario Division, is part of a worldwide family who on a daily basis offer humanitarian service to vulnerable population groups. Our international relief efforts in countries like Rwanda make the difference between life and death for people caught in horrific circumstances.

We are equally proud of our local efforts to provide help when help is needed. The Canadian Red Cross Society, Ontario Division, operates 78 branches across Ontario, offering services such as disaster relief and emergency training, blood collection and distribution, water safety and learn-to-swim programs, first aid and CPR training, and education in international humanitarian law and the terms of the Geneva conventions. In addition, almost all of our 78 branches, 10 of which are in the southwest region, run community-based long-term care programs such as homemaking, transportation and meal programs, home health care equipment loans, home maintenance, security checks and friendly visiting. The services are provided through the efforts of over 10,000 volunteers and 6,000 staff. The majority of those 6,000 staff are trained homemakers.

The corporate culture of the society is based on seven fundamental principles, including humanity, impartiality and voluntary service. As an international moral force in the world and the founder of the first homemaker service in Ontario, we can easily lend our support to a client bill of rights.

We support the concept of aging in place with accessible, responsive, quality-driven, coordinated, cost-efficient services that promote independence and choice and avoid inappropriate institutionalization.

Notwithstanding these areas of agreement, there are areas of Bill 173 that cause the Red Cross concern. Generally, we find the draft legislation is too prescriptive. It attempts to build a complete long-term care structure rather than a solid foundation upon which long-term care can evolve and grow. The legislation must recognize that the demands on the long-term care system and the services it provides will evolve and will change.

As currently drafted, the legislation prevents the Red Cross from becoming an MSA or even providing services as part of an MSA. The current community system has many strengths which the legislation could and must build on. Experienced community-based organizations such as Red Cross, with local boards, a proven track record and highly motivated staff and volunteers, are one of these strengths. It is unbelievable that the government would intentionally establish a system that ties our hands.

The recently announced memorandum of agreement between Red Cross, VON and Home Care in Windsor is a perfect example of building on existing resources to enhance service delivery. The agreement outlines a collaborative relationship that will attempt to achieve a number of the initiatives of long-term care reform, including improved access and better-coordinated service. An executive summary of this cooperative endeavour is at the back of your package.


The government's push to implement draft legislation is confusing and frustrating at the local level. People are looking at this legislation and even in a draft form are trying to make it work. And as much as we'd like to say we have cooperation in communities, we have competition right now. Organizations are deking it out and people are still needing service while we're at the table deking it out. It's a waste of time and energy.

The wording of the legislation significantly devalues the role of the homemaker and may lead to a reversal of the growing appreciation of the homemaker as part of the health care team. The society has historically recognized how valued the front-line worker is to the client. We have put supervision, education and risk management processes in place to support homemakers and volunteers in the difficult job they do out in the community.

Our brief recommends three specific sections of the draft legislation that require amendments in our opinion. All would enhance the delivery of long-term care, specifically in part II, which deals with the categorization of community services.

Patterns of care are evolving rapidly. So are the scope and professional standards of each profession. In the future, new and different services will be required. There is no provision for this evolution in the draft legislation. In addition, the somewhat arbitrary division between homemaking and personal support services does not reflect today's reality or emerging trends.

Our recommendation is that the legislation be reworded to eliminate the specific references and categorization of community services, that the regulations to the act be used to define those services provided by an MSA, and that the act and the regulations respect the interrelationships of the professions and the work that the individuals are doing.

Part VI, section 13 sets limits on the MSA, this 80% you've been hearing about. All of us, I guess, are at you about that. Certainly our recommendation around that is that the legislation be reworded to remove the limits on the amount of service an MSA can purchase, and that the legislation enable each community to choose the best service delivery model and optimum mix of provider agencies to meet the needs in the community.

Our third recommendation deals with part VI, section 15, the section that requires the MSA to comply in four years with the provisions of the legislation. We recommend that this four-year time frame be eliminated.

I'm the lead act, so to say, and Mr Willms is going to offer some further comments.

Mr Walter Willms: Thank you, Mr Beer, members of the committee. It's indeed a pleasure to be before you again after six years of retirement, and it is doubly a pleasure to be here to represent the Canadian Red Cross Society, which is the world's greatest humanitarian organization.

I am delighted that I've been asked to be a spokesperson to comment on the Red Cross position as it pertains to Bill 173. I have had an association with the Red Cross for more than 50 years, as a student, a teacher and a blood donor. For nearly six years now I've had volunteer involvement in planning, policy-making, operations and management at branch, region and division levels for the Red Cross. Currently, I am the president of the local branch.

I want to reinforce the position of the Red Cross that has been articulated by Mary Kay Croft and add to it some of my personal comments at a ground, grassroots level, because I believe I've had some involvement in the community which permits me to do so. First, what in my opinion may be some consequences or implications if the above concerns -- categorization of community services, limitation on the amount of service that an MSA may purchase, full compliance with all aspects of the act within four years, and the rigid criteria or prerequisites for the identification and designation of MSAs -- are not properly addressed or resolved?

First, in my opinion, valuable community resources -- human resources, a multitude of experiences, existing infrastructures -- will be lost. Undue efforts and energies will be directed to structure and organization rather than applied to delivery of services and the implementation of programs. Viable local options will not be exercised. A whole new wheel will be built or invented rather than existing wheels greased and their individual cogs meshed. Administrative details for implementation, delivery, recordkeeping and funding will become monstrous. Another level of governing bureaucracy will be created to oversee existing viable bodies whose roles will be dramatically reduced or altered or, worse yet, take over such bodies whose demise we may experience.

My personal background or experiences cause me to make some further comments at a layman's level. I am or have been a primary care giver for a mother, now age 88, and a mother-in-law, now age 83, each living independently with appropriate support systems; a wife who is a severe asthmatic; and a son who was a severe diabetic, lost his total eyesight at age 30 and died of a heart condition six years later.

In fulfilling my care giver responsibilities, I have had involvement with several community programs and services: VON, Home Care, Homemakers, Meals on Wheels, telephone assurance, security checks, transportation, home maintenance, and social and physical services of the CNIB -- orientation, mobility, grooming and household safety. I am or have been involved with several community agencies in addition to my involvement with the Red Cross, namely:

(1) At a senior citizens' centres association I am a planner, a policymaker, a resource for staff and a provider of transportation services.

(2) I am involved with the Rotary Club, particularly with the adult assistance committee.

(3) I have been involved with the CNIB, the council on aging, children's rehabilitation centre and citizen advocacy.

(4) I have been very involved with the United Way for more than 30 years.

Thus, I believe I can make some personal comments with respect to the Red Cross position and the content of Bill 173.

People's needs and our appropriate responses to those needs do not fit into neat categories. The whole person must be treated. Coordinated, not categorized, services are required. The type of service, the intensity of the service and the priority of service can and do vary and fluctuate frequently. I know that from my experience with my mother.

The local, autonomous requirements for the designation of MSAs preclude the use of existing infrastructures such as the Red Cross. I might also name the CNIB, the Canadian Cancer Society and others. Such provincial or national bodies will not collapse or disappear; they will find new niches. The proposed designation of MSAs may well force the demise of local organizations that have developed effective responses to local needs and priorities. Their loyal and committed followers, supporters and volunteers may not readily and quickly adjust to a new bureaucracy which for sheer size may be perceived as remote and faceless.

The limitation by category on the amount of service that may be purchased will prevent MSAs from purchasing from existing stable structures which have a proven track record in the delivery of community services.


Legislation must provide for an umbrella or a coordinating structure which will stimulate a sharing among organizations that are incorporated provincially or nationally. Legislation must promote, for a merger or a cohesiveness, a coordination of local autonomous groups, local groups that have local charters and incorporations.

The 20% limitation on services that may be purchased, in my opinion, should not be applied to services that may be purchased at the local level from well-established not-for-profit organizations.

With today's technology, personal assessments, access to a multitude of services, recordkeeping and scheduling of services can and must be centrally coordinated. We have heard about the idea of one-stop shopping.

The actual delivery of services may well be handled by various agencies and structures which already have the infrastructure necessary to do so.

The user, the person for whom we want to provide in order that he or she may be spared from being institutionalized, cannot and does not want to deal with many contact points. If I wish to bring my mother, when she is able, to our home or to one of my siblings' homes for a couple of days, she or I must make at least five phone calls: VON, homemaker, Meals on Wheels, telephone assurance and security checks.

The system must respond to little things which are important for the whole person and which, unfortunately, easily slip through the cracks in a system that is rigidly categorized. This past winter, with its prolonged cold spells, seniors for whom I provided transportation for medical appointments and other legitimate needs were frustrated because they hadn't been able to walk to the corner to mail letters or cards, a very important part of living for them.

Albeit social and recreational services are identified in the proposed legislation as community support services, there has been, in my opinion, very little evidence in local planning communications to suggest that important wellness initiatives endeavours will be appropriately recognized. I think the legislation could be strengthened in this regard.

Finally, as already has been said, earlier this week representatives of the local VON, the Red Cross homemakers and the home care program proudly announced the signing of a memorandum of agreement which forms a basis of a cooperative operating agreement designed to enhance service delivery of applicable services within our local community. Legislation must promote, legislation must enable more such agreements to be negotiated. Bill 173, as it is currently written, will be restrictive in those matters which we have identified and briefly elaborated on today.

I believe we must seek coordination, unification and cooperation and then develop the structure, rather than identify and designate a structure and thus force other bodies to succumb or to disappear.

Thank you for listening to us. We shall respond to questions that you may have.

The Chair: Thank you very much for the submission and for the copy of the memorandum of agreement, which is quite interesting, as well as, I just note for the record, the statement on the Canadian Red Cross and the positions that it's set out. We'll move to questions.

Mrs O'Neill: Thank you very much for coming. You're likely aware that you're not the first Red Cross that's come before us. I think the people in the north are really in desperate positions because I think there is a minimum of 25 communities that have no alternative but the Red Cross. These communities know that they are not going to have the same service under the same governance structures, with maybe not the same people, with an MSA. I think that is almost criminal; it's certainly incredible.

I find it very difficult that we would be dismantling the service of an organization such as yours and building something else in the service of home care, because your reputation precedes you, as I said.

I wonder if there is something you could tell us -- I presume you're talking about a federated system, now that you've signed this memorandum of agreement. Could you tell us a little bit about that, how it came to be and what are some of the key features? Hopefully, that will be part of an MSA.

Ms Croft: Hopefully it works, if we can accomplish the principles, whatever you call it, it's working, it's meeting the principles and the goals. The name doesn't really matter.

The way it came about was rather interesting. A lot of talking preceded it, and sounding out and identifying needs. What it amounted to was that we saw some opportunities. We placed a Red Cross supervisor in the home care office for a period of three months. Home care in Windsor is administered by the VON. We have home care, VON and Red Cross all in the same office now, which is really remarkable, for those who are familiar with the system and with the purchase-of-service mentality that has gone on historically. "I'm paying you. You do what you're told and if you don't like it, I'm going to go to somebody else. Don't complain and don't manage the case. Just do what you're told."

This concept was really good, that we'd all get together and hunker down for three months. During that three-month period, all of us identified areas where there are opportunities to become more efficient in terms of how we take information in, how we give information out, how we record it. It's the right hand talking to the left hand. Recognizing that, we then wanted to formalize our agreement and state our intentions right up front to the community, to the workers in our organization, to the volunteers. Within the agreement the roles of the three agencies are clearly identified. VON has agreed it's not going to do homemaking service. Red Cross has agreed we're not going to be doing nursing. In some communities, we're deking it out. We're saying: "I'm going to do it." "No, you're going to do it." "No, I'm going to do it." We said: "Look, VON, you're great. You're great at doing nursing. We're great at doing homemaking. Let's do what we're good at. Home care, you're good at case management. Do what you're good at and let's all do it together."

The memorandum very clearly outlines the roles of each. It establishes a volunteer advisory committee. It will be made up of some of us service providers who are involved, volunteers from the community and one other individual at this point; the district health council has asked to have a representative on that advisory council. That's the stage. The stage is set. We've identified our objectives, which are very much taken out of the long-term care document. You've set the stage, you've set the principles, you've made us look at it. Some of the goals that we've set are to look at our information systems, our communications systems, our intake process.

Mrs O'Neill: Are you, this body -- I don't know what you're calling it -- part of the scheme of the district health council's long-term planning committee? Are they looking at this as a possible MSA foundation? Where do you fit into the planning?

Ms Croft: I might ask Walter to comment on that. We did meet with the district health council before making the announcement. I will tell you that the three organizations pretty much had the concept nailed down when we went to the DHC, but the DHC did offer us comments.

Mr Willms: Further to that, I might add that there was discussion, that members of the Red Cross and members of the VON have served on various community committees under the jurisdiction of the district health council, so there has been liaison and involvement.

In addition to what Mary Kay Croft has said, I do want to emphasize that the agreement is at the operational level. There is absolutely no forfeiting, there is absolutely no waiving of any policy decision-making on the part of either body. I think in your question, Mrs O'Neill, you were asking something like, could this evolve into an MSA? My interpretation and understanding of Bill 173 is that it cannot because there is no way that the Red Cross will forfeit or waive its national and international status. Even though we have this agreement, it cannot be the beginning of an MSA under the legislation as it is currently worded. Therefore, we would propose coordinated efforts working under advisory boards. Integrated efforts would be established in order to use those infrastructures that we already have. It may be a federated model.


Mrs O'Neill: Do you feel that the people you serve, your clients, realize the service of the Red Cross is in jeopardy? Do you think that's well known?

Mr Willms: It's not well known, and let me say very quickly to you that the clients and consumers don't care as long as they get quality service. They have no interest in fact that you and I are sitting around the table debating and discussing and analysing structural possibilities.

Mrs O'Neill: So there's no affinity to the Red Cross as such.

Mr Willms: The affinity is to the quality of service.

Ms Croft: I agree with Walter. The most important thing is that the service is delivered. Secondarily, people look at who's got what emblem and what's on, the name. The affinity that we see in our organization is with volunteers, such as Walter, who come into the organization and become our heart and conscience. For people like that in the community, the link with the organization is important.

I think over the long haul the client won't be able to say, "Oh gee, I wish Red Cross was here again," but what they're going to say is: "Oh my God, how did I get stuck in this bureaucracy, how did I get stuck where my worker isn't educated, supervised or supported in the field?" Because they're out there. "How did this happen?" They won't be able to say, "It's because Red Cross isn't here any more." They'll just know they're not going to be happy with it.

The Chair: Thank you all very much for coming before the committee this afternoon. We appreciate it.


The Chair: We call our final witness for these hearings, Joan Cowie, who is the president of Persons United for Self-Help in Windsor-Essex. Ms Cowie, welcome to the committee. If I recall, you were also before us the last time that we were wandering the province, with Bill 101. We very much enjoyed your presentation at that time. I think it's perhaps fitting that we end our hearings here with you and the organization that you are with, because I know from experience the work that you do in the Windsor-Essex area. We're glad to have you even if it is at the end of a long day.

Ms Joan Cowie: I'll be real fast.

The Chair: That's quite all right. You take your time and tell us what you need to tell us.

Ms Cowie: I'd like to thank you very much for allowing me to be here. You'll have to excuse me, I've got a really sore throat. I think I had that on Bill 101 too.

The Chair: Maybe it's something about meeting with us.

Ms Cowie: I don't know.

I'd like to thank the committee for the opportunity. Unfortunately, we didn't find out until 10 to 5 on Friday afternoon that we were coming up, so I haven't had it all typed. I met with consumers Monday and Tuesday, getting bits and pieces together quickly and putting it all together last night at 2:30 in the morning. I hope that you can understand and appreciate how fast this has been done. I'll be real fast.

The Chair: That's fine.

Ms Cowie: My name is Joan Cowie. For those of you who don't know me, I am here representing PUSH -- Windsor and Essex County. PUSH is a province-wide group that advocates and lobbies for the rights of persons with disabilities. We encourage our membership to become empowered and in control, to lead a life more independently.

A little background on myself: I have been involved with long-term care issues for 19 years; I have been addressing them for seven. I am a single mother with two able-bodied children and I have a life-threatening disease. I am a member of the Attendant Care Action Coalition; the long-term care coalition; TRAP, the Tenant Rights Advocacy Project, which involves support service living units; as well as our local long-term care committee of the Essex County District Health Council.

What I would like to address today are the following issues on Bill 173: long-term care services, children's services and consumer direct funding.

We, members of PUSH -- Windsor and Essex County, feel that Bill 173 promises more even and fair distribution of and access to services within individual MSA service areas. We have reservations and concerns that truly comprehensive service provision is not adequately addressed by the bill. In fact, reviewing specific sections of the act, we feel that it largely entrenches the current rate of service providers by allowing them to maintain the control over the nature of the service, the eligibility, the amount, the criteria.

Although the intention of this act is to protect the consumer's right to complete and unfettered long-term care services through a so-called consumer bill of rights and appeal process, none the less ultimate front-line control remains the domain of the service provider.

Despite protection afforded the consumer, and particularly in parts VII, VIII and IX of the act, many consumers will remain reluctant to question or file any complaints regarding shortcomings or outright abuses of any services provided through the long-term care.

Unlike a consumer direct-funding model, where a consumer has and in fact endorses or accepts the policies of a service provider, through these consumers' allocations of long-term care dollars Bill 173 perpetuates a framework which presupposes that existing and future service providers know what is best for their clients or consumers. While this is not a completely wrong-minded or incorrect assumption, it is unrealistic and deterministic.

When the minister addressed these issues at the Woodeden conference on June 14, 1994, which I attended, she spoke eloquently of the need for employment and increased consumer responsibility and various aspects; for example, attendant service, homemaking service, respite care services. Indeed, she announced the implementation of the pilot project involving the participation of 80 to 100 disabled consumers.

Clearly many, if not most, of the consumers or their advocates would prefer direct access to services they require in order to maintain the greatest degree of autonomy. While it is not always feasible to offer complete independence of selection of services, the MSA-based model essentially sets the compendium of services offered and will indeed select those specific agencies and service providers in the community which best fit the MSA governance body's vision.

Respite services are grossly undersupplied in this bill. With greater medical technologies premature babies are living longer lives, consumers with disabilities are living longer and overall our health is improving. Unfortunately, this leaves a terrible burden on family care givers as funding for respite care decreases. More and more parents of children with disabilities are taking on extra attendant care, extra nursing services for their children's needs. Now we have senior parents still assisting with these tasks with their adult children with disabilities. What do you have in the end? A family burnout.

Despite the issue of political correctness, the disabled community feels compelled to criticize the way the long-term care act is slanted more towards seniors, instead of persons with disabilities and children with disabilities, in terms of the funding envelope. The majority of the funding is slanted towards seniors. One example of this bias, our local health care, is the quick response program. Although this program will deal with treatment of a disabled adult, such knowledge is carefully concealed from consumers and not commonly known in the community. Clearly, the QR program was designed to service and meet the needs of seniors. Contrary to the beliefs of acute care hospitals, mechanisms are not always in place for post-release care for disabled adults.

We have many questions and comments for this committee. I'd like to read them.

What about service for families of a child who fits this bill? If a parent is hospitalized or an emergency arises and he or she cannot be there to assist, does the ministry lift its rate or dollar that is allotted and provide more service? Who decides how much more service one gets? What may seem to be logical to the minister can be extremely short to the consumer who lives with this issue day in and day out. Who will be responsible for the consumers? Who will be responsible to the consumers who fall through the cracks in the system and who continue to fall through the cracks in the system in this act?


We would like to know more about the direct funding. The minister announced direct funding through a pilot project on June 14, but in Bill 173 the control is still in the hands of the service provider. Consumers and service providers must have a good working relationship to both be successful.

Eligibility: How does one determine this? By income? If so, do you take into consideration how much one pays to maintain that consumer at home?

Ministry must change guidelines. When RN services needs increase, do not increase the homemaking. Ministry must go by a consumer-needs base. What about waiting lists? For some, the list can seem like an eternity. What is the ministry's definition of "services shall be planned in a timely fashion"?

Consistency within long-term care has not been properly addressed. We the disabled community need a clear definition of services from cradle to grave. Think of all the family criteria and families who must encompass all the children and all the disabilities. We must have a choice.

When a consumer goes into a hospital, do you have to reapply for these services after you're discharged? Will the doctors understand that? They just discharge you and you've got to wait 24 hours before your services start up again.

What impact will this have on long-term care services? We would like to comment that people with developmental disabilities are not even addressed in this act. We would also like to comment on a direct quote from Ruth Grier from Woodeden. She said:

"It goes a long way towards achieving this government's goals to expand community-based services, services that promote independence, that are consumer-based and accountable to the community, and that respond to the needs of the individual....

"You've told us time and time again that people with disabilities want to develop a self-managed model for attendant services that gives them greater control and choice──one that promotes individual responsibility and encourages full participation in community life──one that permits you the flexibility to design your services around your needs and lifestyles."

Please, as a committee, seriously consider that Bill 173 in its current form facilitates these objectives. Thank you for your time and your attention on these issues, because everyone at one point in their lives will soon require long-term care.

Mrs Cunningham: I think most of us get some pretty good direct recommendations from your organization, not only of course in the Windsor-Essex area -- I can speak for London, and there are others. I would like to congratulate you for being involved with PUSH because some of the practical things are missing some days when we're trying to change things for the better. I guess that's why we've got the hearings.

I made notes of what you stated and the appeal process is of concern, a tremendous concern. Also the fact that you're concerned about fair access to programs, long-term care type programs for children, certainly has been raised on more than one occasion today. The fact that you introduced the respite services, so important --

Ms Cowie: Yes, my mother's very tired.

Mrs Cunningham: Yes, I was thinking the same thing, this thing about burnout some of us relate to, waiting lists being a criterion and what not. I think from what you've stated -- I'm going to ask you a question -- is it fair to say that one of your greatest concerns is this direct care funding model, the one where you get to pick, and that there shouldn't be a cap on this 20%, so you can choose who you need to provide the services that you want?

Ms Cowie: Yes, it's very frustrating to sit back and know that consumer-direct funding has been effective immediately and there has been no direct funding given out to anyone in the province. In my own life I'm a single parent of two small children. I have a total of 17 different attendant care people who come in and service me in a month. I have to say the Canadian Red Cross is very good with their homemakers; they keep them consistent. But you're trying to raise a family and you're trying to teach your children about strangers. How can you teach your children about strangers when there are so many different people coming into the home?

When you have respite come in, there are about seven or eight who do a weekend, 24 hours for three days, so there again, it's very frustrating as a disabled adult to sit there and say to your children, "Don't talk to this person, don't talk to this person." "But, Mommy, they were at our house last weekend." It's frustrating for the families, and what I think the government really needs to understand is that there is only one main care giver. So many times agencies come to us and say: "How many brothers do you have? How many sisters do you have? Your brother lives in the States. Could he come over for a weekend?" "No."

There's one main care giver and the main care givers are getting burnt out, they're getting older, and it makes you feel like a burden on them and it makes you feel very guilty.

Mrs Cunningham: Well, Joan --

Ms Cowie: The direct funding, yes, would make it a lot easier because you could hire in whoever you would like. You could have your attendant services and your homemaking services done all by the same person and you could maybe hire five to seven people, have five people and then two as a backup for vacations. That way it ensures continuity in the home and makes for a better relationship, not just between the attendant and the consumer, but within the whole family, because many times, agencies will say, "We don't have anything to do with the family."

Whatever person walks through the front door has to deal with every single member of the family, whether it's the parents, the children, the brothers, the sisters, the aunts, the uncles, grandparents, whoever. Consumer-direct funding would alleviate a lot of headaches for a lot of people with disabilities who are willing to manage their own services.

Mrs Cunningham: Thank you for telling your story. I sure relate because we have a care giver in our home for my 25-year-old son and, if I had to go to the extent that you have to go to, I don't think our family would have survived.

The first care giver we had stayed with us for four years and was a member of the family, and I thought was well paid. It would have cost me, if I had used the agencies, eight times the amount of a very fair salary for a very wonderful young man who got his degree at the University of Western Ontario at the same time as he helped us, with all of us helping out.

There are wonderful ways to make it happen, but I always said when I was at Merrymount, I could not have raised my children with the demands that were put on those single parents to, first of all, meet all the criteria so that they could pick up the help that all of us have worked for to give them while they were raising their children.


So I understand what you're saying. I think we get caught up in so much bureaucracy --

Ms Cowie: There was one meeting I came out of, a subcommittee meeting that I'm a chair of from the long-term care committee. I walked outside of this facility and I started to cry. It was because I'm caught in the bureaucracy of everything that's going on.

I just want my service. This is what want, this is how I want it done. I don't need this, this, this and this; I maybe just need this and this. It's very frustrating to get this across to the government. You come and you speak, and we've been speaking on this issue for so long, trying to get someone to listen to us. It's impossible.

Mrs Cunningham: There are a few of us that definitely relate, sitting around this table, because so many people are involved. Taking a look at the numbers that the Red Cross provided us with today, by the year 2010 -- what is it? -- 63% in some way will require these services. If we can't get it together, we're going to have a lot less productivity in our families and in our society. I think your children are the young people we're trying to influence.

Keep fighting, because you've made tremendous gains. We really respect the fact that you're here today and we are listening.

Ms Cowie: I don't want any child with a disability or their parents to have to go through what my parents did. I'm 25 and my mother sleeps over seven nights a week because we don't have respite care or the extra care that we need. I feel like a burden and I don't think that's fair to my mother. She is going to be in need of long-term services if this does not start moving and moving smart. Let's get it together. Let's not bicker at tables and about agencies. I'm tired of that. I want to get to work. Let's just have the service for the people and let's do it.

Mrs Cunningham: Has anything improved since the last time you came before a committee of the Legislative Assembly?

Ms Cowie: The last time I came to your committee I was still having the problem that my attendants will not serve -- before, prior -- they wouldn't serve my children the same meal as they will serve me. They still won't do that, the attendant care agency. They want a homemaker and at the same time -- my seven-year-old has grown up a lot and I usually put his meal and my youngest son's meal on a plate and he carries it to the table. So, no, it's not making it any better.

I was given hope with the consumer-direct funding on June 14. I met Ruth Grier outside and I talked to her and I told her how important it was. They have to understand that there are people with disabilities whose children are growing up. They're getting married. They're having a job. They're going to school, having a job, having children, then their children are growing up. They need a little bit of assistance. They need that extra arm --

Mrs Cunningham: And some common sense.

Ms Cowie: Yes. But otherwise I'm still fighting.

Mrs Cunningham: Keep on.

The Chair: The parliamentary assistant wanted to respond to one of the points that you raised.

Mr Wessenger: It's certainly good to hear from you again. I know you'll be very interested in the direct funding pilot project that's going to commence this fall. I just wanted to make it clear on the record that the funding for that direct funding model is not part of Bill 173; it's funded under the Ministry of Community and Social Services Act.

The Chair: I want to thank you for coming before the committee. I recall the last time when you were before us and indeed remember the example which you just used. I think sometimes we have to be saying to ourselves, "Look, we've got to make progress and we've got to find ways to find solutions." I think we are all amazed, frankly, at the energy that you continue to show and we all wish you the very, very best. If you have to come before this committee again --

Ms Cowie: I hope I get invited.

The Chair: -- we desperately hope that a lot of things will have happened and a lot of things for the good. So thank you very much.

Ms Cowie: Thank you very much for having me.

The Chair: Members of the committee --

Mrs Caplan: If I could interrupt just for one second, actually in an aside that I think Joan might be interested in, I asked Mr Quirt quietly when they thought the independent funding model might be in place and he said October.

Ms Cowie: But there's only 80 to 100. In that 80 to 100, how do you know if you're going to get chosen, and will it go all over Toronto? Will it come down to --

Mrs Caplan: All I can tell you is that -- I was concerned in June that there was no time line -- at least you'll have the answers to those questions by October.

Ms Cowie: Right.

Mr Quirt: The design of the direct funding pilot was assisted by folks from ACAC, the Attendant Care Action Coalition. They were involved with us in designing it. People from the independent living centres are helping us do the selection of those 80 to 100 people. Clearly it won't be all people from Toronto. I understand that there's a good representation of applications from the London area.

Ms Cowie: I hope it comes down to Windsor.

The Chair: Thank you very much for coming before the committee, and a safe trip home.

Ms Cowie: Thank you very much.

The Chair: Members of the committee, before we disperse, just two things: One, those of you who are taking the bus back to Toronto, it awaits you as I speak. So if you could get back to the hotel, it will be there, and pick up your bags. We now will be meeting again in Ottawa, beginning on September 12. While that may seem like many weeks away, I'm sure it will come quickly.

If I could, as a final word, just thank everyone --

Mr Wessenger: I think we have one left to do. We have some information to provide to committee members. We'll get it to the clerk and it can be distributed. This is in respect to the request for information that had been put in the previous occasions.

The Chair: Could I just ask for the record what that information is?

Mr Quirt: There are three things being distributed that were requested. One is a description of the former not-for-profit policy and the new requirements under the bill with respect to purchasing limits in the categories.

The second thing that was requested was a list of those capital funding projects that had been approved for homes for the aged and other seniors programs for 1993-94 and 1994-95.

The third thing that's being provided that was requested is a comparison of the aspects of a service coordination model vis-à-vis an integrated model with respect to the objectives of the bill.

The Chair: Those members of the committee who aren't here at this time, we'll make sure they get copies of that.

With that, members of the committee, we stand adjourned until Monday, September 12, in Ottawa.

The committee adjourned at 1827.