Tuesday 12 April 1994

Dialysis treatment services

Kidney Foundation of Canada, greater Ontario branch

Catherine Johnston, chair, government relations committee

Janet Bick, advocacy coordinator

William McCready

Dawn Evans

Scarborough Renal Dialysis Working Group

Dr Robert Ting, staff nephrologist, Scarborough General Hospital

Jagsarran Beechan, renal patient

Dr W. Berry, nephrologist, Centenary Health Centre

Keith Spiegelberg, executive vice-president, finance, Scarborough General Hospital

Dialysis Management Clinics Inc

Igal Holtzer, partner

Noel Egguera, renal patient

Franca Tantalo, chief executive officer

Carol Holtzer, president

Edward Cole


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:

Haslam, Karen (Perth ND) for Mr Hope

Sullivan, Barbara (Halton Centre L) for Mr McGuinty

Wessenger, Paul (Simcoe Centre ND) for Mr Owens

Also taking part / Autres participants et participantes:

Wessenger, Paul, parliamentary assistant to Minister of Health

Clerk / Greffier: Arnott, Doug

Staff / Personnel: Gardner, Dr Bob, assistant director, Legislative Research Service

The committee met at 1534 in room 151.


Consideration of the designated matter pursuant to standing order 125, relating to dialysis treatment services.


The Vice-Chair (Mr Ron Eddy): Good afternoon, ladies and gentlemen. Welcome to the standing committee on social development, which is presently holding hearings under standing order 125, the designated matter being dialysis treatment services.

The first presentation is to be made by the Kidney Foundation of Canada, greater Ontario branch. Would the representatives come forward. Please be seated, introduce yourselves and proceed with your presentation, and we hope that at the end of your presentation there will be time for questions. Welcome to the committee.

Ms Catherine Johnston: Thank you, Mr Chairman and members of the committee. My name is Cathy Johnston. I'm here representing the Kidney Foundation. With me I have Janet Bick, provincial advocacy coordinator for the foundation, and Dr Bill McCready, chairperson of our Ontario medical advisory committee.

We have a written presentation, which you have in front of you. In the interests of brevity I will highlight those areas I'd like you to pay particular attention to, but encourage you to read our entire presentation at your leisure because there's information in there that I'm sure will help amplify and explain some of the things we'll be saying. I thank you again for allowing us to make a presentation to your committee, and perhaps to start, a few words about who we are.

We are a national volunteer organization and we are dedicated to improving the health and quality of life of people living with kidney disease. The Kidney Foundation funds research, provides services for those special needs of people living with kidney failure, actively promotes an awareness and commitment to organ donation and, most importantly, we advocate for access to high-quality health care. It's this final goal that brings us here today, as we believe that without a stronger commitment by the Ministry of Health to the growing crisis in the provision of dialysis services, our access to high-quality health care is in jeopardy.

I'm here as a volunteer with the Kidney Foundation. I'm chair of our government relations committee, but I think most importantly, I am one of the 5,600 people living in Ontario who are being treated for kidney failure. I am someone who relies for my life on dialysis. Without it, I die. Without it, I wouldn't live a week. That's a fact we cannot avoid when we're talking about dialysis.

The number of patients continues to grow, every year, 8% to 10%. There's no reason to expect that will change; that has not changed in the years past. There's no cure. There are only three ways to be treated: two kinds of dialysis, or transplantation. That's it; there is no other way.

People with chronic renal failure face tremendous physical, psychosocial and financial burdens. The time invested demanded by dialysis treatments is significant and generally interferes with normal living patterns. As an example, I work full-time -- I'm fortunate enough to be able to do that -- but three nights a week, Monday, Wednesday, Friday, I spend four hours hooked up to a machine. That is my life. That does interfere with a normal life pattern, I'm sure you can agree.

We suffer from fatigue and a variety of other physical discomforts, we have the strain of coping with a chronic and life-threatening illness, and many others have multiple medical problems in addition to this. We have a restrictive diet, curtailment of fluid intake, and extensive drug therapy. This is all part of what we live with every day.

We face extraordinary costs related to our illness. We have to get to our treatment. Some of us need special equipment. We have medically necessary prescriptions and over-the-counter drugs not covered by hospitals, private health plans or the Ontario drug benefit program. Support services available to patients through the hospitals such as drugs, transportation subsidies, parking, meal allowances and accommodation costs for training are being continually eroded.

Living with kidney failure imposes continuing stresses on families and family members, including treatment restrictions, and financial worries and constraints. There are strains on marital relationships. We have to worry about the side-effects of drugs. If we've had a transplant, are we going to be able to keep that transplant? We live with the threat of death. And once diagnosed, we're on some kind of replacement therapy for the rest of our lives.


The lack of a comprehensive long-term plan for dialysis and transplantation services in Ontario, combined with the steady growth of the renal failure population, decreasing transfer payments to hospitals, social contract -- all of these things are placing increasing pressure on dialysis programs, and the provision of high-quality health care for kidney failure patients is threatened.

In 1989, the previous government announced the allocation of $23 million to expand dialysis services across Ontario, but unfortunately these allocations weren't made as part of an overall plan or with regard to future growth. We've seen the recent opening of a new regional dialysis centre in Orillia and the Sussex Centre for self-care dialysis in Mississauga. These are the last of the phase 3 proposals to become operational. Orillia is already full and has a waiting list, and the situation at the Sussex Centre is no better.

At this time, there are no plans to expand dialysis services anywhere in the province. In some parts of the province, patients can't be offered a choice between kinds of treatment because there's an overcrowding of the facilities that are there. In some instances, people are waiting longer to commence treatment than is medically recommended. They're sicker before they can begin treatment because there is no room. Transfers from one treatment to another, for good reasons, are hard to arrange.

There's an extreme difficulty in providing flexibility of schedules to accommodate employment. My employer could come and spend an hour with you and describe the difficulties of employing someone who has to work their schedule around a dialysis schedule when they can't make alternative arrangements, can't move their time no matter what because there is no flexibility, there is no room.

Children who are on dialysis are having problems being transferred to other hospitals when they're old enough to be treated in an adult program, because there is no room.

Most haemodialysis units can't accommodate visiting patients. It has become increasingly difficult, and impossible in some instances, to travel for business, to attend to family matters or family emergencies or simply to go on vacation within Ontario. I could spend another hour with you telling you about the difficulties I've had trying to receive dialysis in Ontario other than in my own home unit. To try to come to Toronto is a major problem.

In the Toronto region, some people have no choice but to spend weeks in hospital to receive treatment. That causes unnecessary disruptions to employment and family life. Patients in many parts of the province are travelling up to two hours each way, three times a week, to get to dialysis, because there's nothing closer to them.

Many hospitals are straining just to provide access. Dialysis units are full. There's no more room. And we know that the patient population is growing at a rate of 8% to 10% a year. Where are we going to put them?

These conditions aren't confined to any one particular part of the province any more. Access to dialysis treatment is under threat across Ontario. Ultimately, the cost is going to go up. As our numbers increase, as patients are waiting longer to receive treatment, that results in longer and more frequent hospital stays, more frequent medical interventions and poorer prospects for rehabilitation.

The Kidney Foundation identified the lack of long-term planning as a key concern. We addressed this by forming a planning group with a two-year mandate that has brought together patients, nephrologists, health professionals, hospital administrators and others. This working group on renal services is trying to develop recommendations for province-wide standards of care, prevention strategies and other areas of concern. The working group conducted a comprehensive survey of all Ontario nephrology units which has revealed a wide variance in the delivery of dialysis care and provides confirmation of the need for a comprehensive province-wide plan.

We're also a member of the steering committee for the central-east dialysis planning group, a project funded by the Ministry of Health and conducted by the district health council. We're concerned, however, over the considerable delay in getting this project started. They haven't had their first meeting as yet.

While the work of the working group and the central-east dialysis planning group moves forward, the immediate needs of kidney patients across Ontario have to be met. The Ministry of Health must not use the excuse that it is waiting for the recommendations of these groups to delay decisions affecting the provision of dialysis treatment for those who need it now.

As an example, we've worked very hard together with the Toronto dialysis committee to encourage the Minister of Health to take immediate action to address the overcrowding situation in Toronto, and we're disappointed with the lack of adequate response from the minister.

The Kidney Foundation advocates for access to high-quality care for all people living with kidney disease. We support the delivery of the most efficient and effective dialysis and transplantation care for everybody who needs it. We believe this can best be accomplished in Ontario by proper planning on a regional and province-wide basis.

The population is growing, and it's the responsibility of the Ministry of Health to ensure that appropriate services are available to meet the needs of this group of Ontarians who depend on this life-saving treatment.

Advances in dialysis technology and the development of more effective drugs to prevent rejection in transplantation have made treatment for end-stage renal disease possible for most people requiring it, regardless of age or other medical conditions. Better planning and an efficient management and delivery structure will ensure high-quality care, consistency of service and a maximum return on public funds allocated to treatment.

In serving the needs of people with kidney disease, the Kidney Foundation is committed to working with the government to achieve the most efficient and effective delivery of renal care to all those who need it.

We urge the members of this committee to make strong recommendations in your report to the Legislature regarding the need for solid government commitment to long-term planning for dialysis care, as well as immediate solutions for today's crisis. People's lives will depend on it.

We'd be happy to entertain any questions.

Mr Jim Wilson (Simcoe West): Thank you, Ms Johnston, for coming here today along with Ms Bick and Mr McCready. I know it was short notice. I should explain that my resolution was sort of crammed in at this point, in case the government sends this committee a piece of legislation; therefore, we wouldn't be able to debate the resolution because legislation takes precedence in terms of the committee's time. I do thank you very much for a very comprehensive brief on short notice.

Also, please take back to your board my thanks for the presence of Janet Bick. In my community, she's worked with my constituents and with the local Kidney Foundation branch, and we've been very grateful for her input. Thank you, Janet, on a personal note.

Having said that, I sense the frustration the foundation has had with this issue. The intent of these hearings is to try and promote the issue as a priority with the government, and we hope that will be the response, that the government will say, yes, we've got enough evidence now to show that not only is long-term planning needed but, as you mention in your summary remarks, immediate solutions are needed.

Before I get to the immediate solutions, though, I want to ask you about some of the history. I'm new to the issue, because constituents came to me quite a few months back and asked me to get involved. You're living with kidney failure and are a long-time member of the Kidney Foundation. The government has had lots of warning about this crisis. Why, do you think -- and I want your candid opinion -- is there foot-dragging on this?


Ms Johnston: I think there have been some numbers games being played, arguing about whether we had a crisis or whether we didn't. Money has always been a problem, and it's hard to set priorities in the health care area where there are so many competing interests. I don't think anybody set out to purposely curtail dialysis. I think that it's just there are so many competing interests and there was a problem in establishing to the government's satisfaction that we had a problem.

Mr Jim Wilson: I appreciate your response, because that's been exactly my feeling. I feel when I deal with bureaucrats at the ministry and in talking privately and in the Legislature with the minister that certainly their perception up till now has been that there really isn't a crisis, that they've got other problems that are more serious.

I guess I can't understand that in terms of, as you said in your own comments this afternoon, you have no choice but to be dialysed, either that or a transplant, and transplants have plateaued. You mentioned in your brief that they've actually decreased over recent years.

We finally get this thing as at least getting the government to acknowledge the need for the central-east study, and it announced the money informally in November. I have the press release here and I talked about it prior to that, in September or October. I was under the very clear understanding that six months later or so we would have the end of that study, and you've indicated, and it's important the members know, that they haven't yet had a full-fledged meeting.

Ms Johnston: I think they have a meeting scheduled for this Friday. That is their first meeting.

Mr Jim Wilson: Do you have any thoughts on that process? Because there was a very specific promise made by the ministry and it's just not been kept.

Ms Johnston: I think maybe I'll let Janet answer that, because she has more familiarity with that.

Ms Janet Bick: I'd like to give you a little more of a historical perspective on the central-east planning committee. The life of the central-east planning committee in fact did not begin last September, but almost two years ago this very month a first meeting was organized by the chairman of the Toronto Dialysis Committee to bring together ministry, district health council, hospital administrators, the Kidney Foundation and nephrology division heads to look for some response to a situation that we see today that was already existing at the time, two years ago. We participated in that meeting.

At a subsequent meeting in May of that year the recommendation was made that the district health councils should undertake to put together a central-east planning group. In November 1992 that group was actually put together under the auspices of the central-east DHCs with some administrative support from the Metro DHC. That group met for approximately four or five meetings between December and the end of March 1993 and then was disbanded at that time because it was felt that there were not adequate resources available to do a proper plan.

At that point they sent out letters to all the various players -- the hospitals, ourselves, the Ministry of Health -- asking for funding in order to hire a health planner and carry out a proper plan. We were willing to provide some funding, provided that everybody else was ready to kick in. That wasn't the case. At that point I believe they turned back to the Ministry of Health. The $100,000 eventually was allocated last fall.

We're looking at a problem that was identified two years ago, and it is only this week that the committee will properly meet to really tackle the issues. They are meeting to tackle the long-term plan, which is clearly needed. In the interim, in the last two years, there's been absolutely no response to the immediate needs. That's the gist of it.

Mr Jim Wilson: That's very helpful.

Mrs Barbara Sullivan (Halton Centre): I was trying to give you a pink flag there, Mr Chair.

The Vice-Chair: Yes, I see.

Mrs Sullivan: First of all, let me congratulate you for the work that you have been doing. I think it is very important to have a full provincial strategic plan in terms of kidney disease that looks at the full continuum from prevention right through to patient services and including treatment. I know, from talking with other people over a period of time, that you are looking at the various modalities and at some of the issues associated, by example, with transplant, including a presumed consent option.

Do you want to discuss that at all today? I have another question, so I want to know how much time I have, Mr Chairman.

The Vice-Chair: You have time for the --

Mrs Sullivan: Do I?

The Vice-Chair: Yes.

Mrs Sullivan: Because I have another question with respect to patient services.

Ms Bick: The working group on renal services has looked at all the four areas of care, which are pre-dialysis, haemodialysis, peritoneal and transplantation, and we expect to have a final report at the end of this year with recommendations that we hope will be carried forward to the Ministry of Health and carried out by the ministry.

With regard to issues around organ donation and the various possibilities of increasing that, I think at this time the national level of our organization is going to be taking a very in-depth look at the problem around the lack of kidneys that are available for transplantation. In fact, we are devoting our entire national annual meeting in June to a workshopping of this particular issue, to looking at it, to looking at some of the alternatives and hopefully coming out at the end of that with some new strategies.

At this time, and I think up until this time, the Kidney Foundation has played a leadership role in promoting organ donation. The multiple organ retrieval exchange -- MORE -- program was originally funded by Kidney Foundation money, as were a number of organ procurement organizations across the country. In all cases they have been taken over as time went by and government funding is what drives them now.

We've also been very involved in a leadership capacity with the national and provincial organ donor coalitions. I think we've come to the point, and I think the point has been made already at these committee hearings, that the usual organ donation awareness programs and so on are just not doing the job and we are hoping to come out of our meeting in June with some new strategies that will allow us to look at ways to increase the supply of organs.

Mrs Sullivan: Good. Certainly the tale you tell with respect to the operation or the beginning of the operation of the central-east planning group is really quite shocking. I know that there were some questions too as to whether a nephrologist would be involved on that committee. Has that been settled?

Ms Bick: There are two committees. There's the steering committee and then there is the technical advisory committee, and there will be, I believe, at least two nephrologists on that technical advisory committee and that technical advisory committee will have one or two members on the steering committee. I do understand that there has been some attempt to see that there is a little more nephrology representation. I'm not sure if that's been resolved yet or not.

Mrs Sullivan: You certainly stress the urgency of not only an interim plan but action in terms of dialysis. Has there been a recommendation for a plan put forward from within the group, from the foundation or from the planning group?

Ms Bick: Again, perhaps a little bit of history on this one. As you understand, this issue has been identified as a problem for over two years. Last year, when the first central-east attempt fell apart, the Kidney Foundation decided that it was time to look at some other strategies for bringing this problem to the attention of the minister.

We arranged a meeting last May. We met with Mary Lewis, who was the executive assistant to Mrs Grier, and brought our concerns to her. The presentation that you saw Dr Mendelssohn give yesterday, he also presented at that time. At that meeting we were promised that this would be looked at. We presented a lot of material, much along the lines of what you see in our package today, and we asked that something be done.


Subsequent to that, the Kidney Foundation and the Toronto Dialysis Committee organized, in June, a meeting again that brought together hospital administrators, division chiefs of the nephrology programs in the central-east area, Kidney Foundation people and ministry personnel to discuss what we can do and to provide some potential solutions. At that meeting, the hospital administrators were told that the ministry would receive and review submissions from them based on the life support formula, asking them to provide what they felt would be their projected dialysis activity for 1993-94 and that these would be considered and that they would have an answer by the end of July. Nothing happened, essentially.

In the last few weeks, it is my understanding that the ministry has taken up this particular issue a little more seriously and there have been meetings between the ministry and hospital administrators and division chiefs. Again they have asked them to submit their projected dialysis activity for the coming year, with the promise that there will be money forthcoming to cover the growth on a one-year, one-time basis, and then looking at what the central-east plan proposes beyond that point. That was my understanding.

Mrs Sullivan: Mr Chairman, could I ask for a response in this area from the Ministry of Health, confirmation of the continuation of the life support formula and the commitment to the attacking of the interim plan through that formula?

The Vice-Chair: At this time?

Mrs Sullivan: Yes.

The Vice-Chair: Can one of the parliamentary assistants --

Mr Paul Wessenger (Simcoe Centre): Yes, I think we have some staff who could probably answer.

Mrs Sullivan: We can have a written response so that we don't have to hold up the witnesses, but I'd like to see that commitment, whether in fact we're dreaming in Technicolor as to whether those life support funds are even going to continue.

Mr Wessenger: Yes, I've requested staff to prepare that.

Mr Jim Wilson: Secondly to that, it's my understanding the approach the ministry's now taking once again is stopgap. It's more of the same old stuff over and over again. I think we should ask for a firm date in writing of when the central-east dialysis study committee is to report. I think they should be forced and the ministry should be forced to adhere to a commitment.

The Vice-Chair: Mr Wessenger, do you wish to proceed?

Mr Wessenger: Yes, in my questions. I gather that you have the overall planning process with your working group on renal services. That's done on a provincial-wide basis on your general strategy, is that correct?

Ms Bick: Yes.

Mr Wessenger: The central-east planning group is on what resources are needed, basically. Is that what you see the role of that, to determine the resources that should be available in the central-east region as the result of that study?

Ms Bick: I've only just, in the last couple of days, actually seen their proposal and terms of reference. I haven't really had an opportunity to review them in detail, so I'm not entirely clear at this point on what exactly their mandate is. I think that the working group is looking at a much broader set of issues than central-east, both because it is province-wide but also because we are looking not only at the basic provision of treatment but all of these support services that have to go along with that.

Mr Wessenger: Yes, I assumed that the two studies were looking at different aspects. Is the central-east the area that has the most resource problems in the province?

Ms Bick: Up to this time, I think it has. We're certainly beginning to see signs of similar problems elsewhere.

Mr Wessenger: Thank you. I have no further questions.

The Vice-Chair: Thank you for your presentation. We're very pleased to have you today.

Ms Bick: Thank you.


The Vice-Chair: The next presentation will be made by Dr William McCready of McKellar General Hospital, Thunder Bay.

Mr Jim Wilson: Just before the witness begins, perhaps the committee could be provided with the terms of reference, when they're available, put together by the working of the Central East Study Committee, so we can know at first hand what exactly the mandate of the committee is.

Mr Wessenger: I think certainly that's a reasonable request.

The Vice-Chair: Would you like to proceed?

Dr William McCready: Thank you. This is a unique opportunity for me. I'd like to compliment the committee, first of all, on having the foresight to ask someone from northern Ontario to present some views to your committee. We're frequently forgotten in many issues, but in health care especially.

The Ontario Ministry of Health faces a difficult dilemma in the provision of care to patients with renal failure. The number of such patients, as you've heard, is growing. It grew by 7.67% between 1991 and 1992, the last year for which we have final information. This growth rate is not confined to Ontario. The rate in Canada as a whole was 9.1%. Indeed Canada's renal failure rate is still lower than that of the United States and many European countries. This may reflect a hidden form of rationing of dialysis, as it's difficult to believe that Canadian patients are really different from their counterparts to the south.

There's preliminary information from a study by our colleague which strongly suggests that family doctors and general interns are not referring all elderly patients for consideration for dialysis. Again, that's likely influenced by their knowledge of this crisis of overcrowding in our dialysis units.

The resources allocated to the management of the population of patients have not kept up with demand. You will no doubt hear of overcrowding and undertreatment in every area of the province. Even when the allocation of funding to a dialysis unit has not been reduced, the impact of health care funding cutbacks has had a profound effect on patients with kidney failure. In particular, cuts to operating room and intensive care budgets have made providing high-quality care to this group of patients, who by the nature of their illnesses are among the sickest of all, most difficult.

To be able to refer a patient with kidney failure who is unlucky enough to have another illness requiring the intensive use of health care resources such as cardiac surgery to an academic centre is now a major challenge for those of us outside the major metropolitan areas. Patients with these complex problems do not always have the highest of profiles. Due to the extreme nature of their illnesses, delay will often end in their death and the end of the problem. There are many examples of this. I'm not going to try to regale you with them, but certainly this is not a theoretical concern.

Other impacts that funding cuts have had relate largely to drugs. Changes in the Ontario Drug Benefit Act have removed a significant number of medications as eligible benefits. While many of these drugs were of questionable medical necessity in the general population, patients with kidney failure rely on these products for their continued wellbeing. A noticeable example is calcium carbonate, a nutritional supplement in the eyes of ODB, but a vital treatment in the prevention of renal bone disease for the dialysis patient.

Drugs with special funding needs because of their high costs have also recently come under threat. Erythropoitin, a drug used to treat the anemia of kidney failure, and cyclosporin, used to prevent transplant rejection, are examples. Funding freezes or rollbacks seem to have been averted for now, but only after intense lobby activity by the kidney foundation.

Proposals to include funding for these drugs in hospital global budgets and comments that delisted drugs should be paid for out of existing budgets totally ignore fiscal reality and further disadvantage our patients.

Ontario has now reached a crossroads in the provision of such sophisticated types of health care. The nephrologists of Ontario are unwilling to act as arbitrators to decide who should and who should not receive such therapies. The need and projected need for dialysis are well known and have been well discussed. The holders of health care purse-strings must indicate if our society can no longer offer treatment to all. Physicians are inclined by temperament and training to treat those who they feel may benefit and who wish to receive treatment.

Patients over 65 years of age starting dialysis are an often-mentioned target in the public eye and the press. These patients have a 50% chance of surviving two years on dialysis. This rate is very similar to the survival rate for colon cancer in the same age group. It does not seem likely that such patients will not be eligible for surgery because of their age, and so it seems logical that age should not be a primary determinant for starting dialysis treatment.


The growth in the number of patients requiring dialysis can be explained by a number of factors. First is the aging population. As we all age, there's an increased incidence of renal failure in older age groups. Second is our low organ donation rate. Third is our increased patient survival on dialysis because of the medical advances made, and here's our dilemma: As we get better at keeping people alive, it costs more, and the dilemma increases.

These factors seem unlikely to change, although public policy changes in the area of organ donation could potentially increase the number of organs available for transplantation. This has been addressed in detail in the past, most noticeably by a task force headed by Dr Calvin Stiller in the 1980s. A number of changes were proposed by that group but few were made.

The recent increase in organ donation rate in the province of Quebec, which followed the provision of financial payments to hospitals which identified and/or retrieved organs for transplantation, points to the fact that public policy can impact organ donation rates. It is to be noted that Canadian organ donor rates are falling behind many other countries, including the United States.

Ontario, however, does continue to treat many patients on forms of home dialysis, such as continuous ambulatory peritoneal dialysis, which are less labour-intensive for hospitals and therefore less costly. Some 47% of all new patients in 1992 started on some form of peritoneal dialysis, and at the end of that year 41.3% of all dialysis patients were on this type of therapy. It is possible that if the resources were available that this could increase a little, but unfortunately not all patients are suitable for this type of therapy.

It is also worth pointing out that while peritoneal dialysis is a very effective form of dialysis, many patients will eventually require transfer to haemodialysis, either on a temporary or permanent basis, mainly because of recurrent abdominal infection. Only 50% of patients will still be on peritoneal dialysis after four years, while more than 75% of patients starting haemodialysis will remain on that treatment. Thus we can expect more and more patients to require haemodialysis in the future, despite the growth of our home peritoneal dialysis programs.

Other methods of reducing costs in the delivery of renal failure care, such as self-care haemodialysis, assisted self-care haemodialysis and dialysis in satellite dialysis units as well as independent health facilities, are increasing in usage, but again not all patients are suitable to receive such treatment.

Many patients across Ontario, especially in northern Ontario, are disadvantaged in their ability to access haemodialysis treatment by the distance they live from large cities. For many the choice lies between home peritoneal dialysis, a move to a larger city, or even death. I would like to emphasize, because I come from northern Ontario, that this is an issue for our native patients especially. Many of them would rather choose death than to move out of their own home community.

Frequently our patients do commute large distances for treatment, but in northern Ontario in particular these distances may be too large or the climate too unreliable in winter, to make such a choice realistic. Experience has shown that satellite dialysis not only allows patients to stay in their own communities but also greatly increases their feeling of wellbeing and hence their ability to cooperate with the complicated drug and dietary regimes necessary for successful therapy.

It thus seems clear that a comprehensive plan to deal with this problem is required. Patchwork solutions can only delay the crisis. As you have heard, the Ontario branch of the Kidney Foundation of Canada and the nephrology section of the Ontario Medical Association recognized this more than two years ago and have set up a task force with the intention of producing a report which gives an overview of the needs of renal failure patients in Ontario.

It will include recommendations concerning all aspects of renal failure management, including predialysis care, haemo- and peritoneal dialysis, transplantation and preventive measures. The challenge will be to ensure that the appropriate resources are then allocated and that future growth in the numbers of patients requiring dialysis no longer triggers the extreme overcrowding and undertreatment that we now see in many of our hospitals, not only in Toronto but province-wide.

A comprehensive revamping such as would be required will take time, and in the interim it is imperative that short-term expansion in services in areas of extreme overcrowding, such as Metro Toronto, be facilitated. Deferring such expansion until further needs assessment is done can only deepen the crisis. It seems foolish to allow the delivery of life support treatment to be driven only by budgetary forces when the delivery of such treatment should be what drives the budget.

The Vice-Chair: Thank you for your presentation. One question each caucus, please.

Mrs Sullivan: I'm interested in two things. I'm going to try to get them all in the same question to cheat the Chair. The first thing is the geographic distribution of services, where typically in northern Ontario where there is a specialized service there are problems with delivery. In fact, I was looking at the numbers of centres where dialysis is provided in the north and see that at least one of those centres is a health centre and wonder, first of all, if you could discuss the use of sites other than hospitals for delivery of dialysis in northern Ontario.

The second thing I just want to know for background information. You and Dr Mendelssohn and the doctor from Kingston, Dr Toffelmire, have spoken really about the kinds of decisions about who will and who ought to receive dialysis. I think each one of you has indicated that you believe that's a question for society rather than for physicians themselves.

But I'm wondering if, as in the case of, by example, bone marrow transplants, there are protocols and standards that are readily definable with respect to who would be assessed and how they would be assessed on the basis of prediction of health benefit from dialysis. If there's a simple form that would explain to us neophytes how that works, ie, what the process is and what those standards are, I think that might be useful.

Dr McCready: To answer your first question first, I believe the health centre that you're referring to is probably in Sioux Lookout, and that's a satellite unit of my own dialysis unit. In fact the district health centre is what they call their local hospital. But there's absolutely no reason that dialysis cannot be provided outside hospital settings. We just happened to rent the space from this hospital because they had it for our unit.

I think that's certainly a very viable and cost-effective way of providing dialysis in smaller communities. You have to recognize that there's no kidney specialist in a small place like Sioux Lookout. Myself and my partner go once a month to see these patients, so they have to be stable patients who don't require a lot of medical attention. That limits what you can do.

All our patients there are native, all are doing extremely well and all are immensely happy to be there. Native patients, if you've ever met native people, are not very communicative and express their gratitude sometimes not at all, but the patients I've got there -- I virtually can't go without getting a gift from one of them almost every time I see her now. It's really amazing and heart-touching to see how well they are doing.

To answer your last question, it's very difficult to predict who is going to benefit from dialysis intervention and who is not. It's pretty easy to say, if you happen to have a terminal cancer, that you really shouldn't go on dialysis, or if you're demented, you're not going to benefit. The choice of whether you start treatment really, right now in my mind, should rightly lie between the patient, the family and the physician, with the help of nurses and social workers. It's a team approach to deciding if people should start on therapy.


Going back to my early days of training in the United Kingdom, there was a committee that decided who could start and who couldn't, and we sent 65-year-old patients home because we thought they wouldn't benefit from dialysis. I can remember sending such a patient home to die from Belfast. When I came to Canada, I met a 90-year-old lady on dialysis. She was sure benefiting and told me about the pioneer days of Canada and how she personally knew the Group of Seven. It was an amazing experience for me.

I think there are many nephrologists in Ontario who are UK-trained, and we're all absolutely opposed to the idea of rationing dialysis based on age and other such criteria. I think if you talk to patients as well, if this is ever brought up at our government relations committee, if you mention agism or sexism or any other ism as a criterion for deciding on dialysis, you'll find our patients are very much opposed to it.

It very often requires a trial of treatment to decide if a patient is going to benefit, and if you actually look at the statistics, you'll find that one of the leading causes of death on dialysis is discontinuing treatment. That's because we frequently will try patients on therapy, find that they really are not getting along with it and then stop. And we have to have the facilities to do that.

Mr Jim Wilson: Thank you, Dr McCready. I think you've given us some very disturbing things to think about. It was also mentioned by Dr Mendelssohn, and we've been presented with the US situation and the statistics there. I guess it's an extrapolation of that or an overlay of that on to Canada and Ontario's population that leads to the conclusion that rationing must be occurring, rationing based on age. Do you have any anecdotal or firsthand evidence, though, that that's occurring in our province?

Dr McCready: Yes, it certainly is. My partner is a younger physician whose wife is an intensive care nurse who works in the hospitals in Thunder Bay that aren't connected to our dialysis unit, so we get to hear about patients who are not referred to us, frequently. I'd like to point out to you that I'm not certain if it occurs the same in the metropolitan areas, but in my dialysis unit, half the patients I see who require dialysis, I've never seen before. They haven't been referred for pre-dialysis care. They suddenly appear when there's a crisis and the family demands that there's some action. Physicians all the time say to me, "I've got this 75-year-old lady with advanced kidney failure, but you don't put patients like that on dialysis, do you?" The answer, of course, is, "Yes, we do."

Mr Jim Wilson: If I could just ask a supplementary: Dr Mendelssohn suggested, for example, that perhaps we should have a liberal intake policy -- small-l liberal -- and get everyone who needs dialysis the treatment. In your professional opinion and in your experience in our health care system, would that not save us money in the long run? If you're dealing with patients who are in crisis and then complications arise, it seems to me they would cost the system a lot more.

Dr McCready: It would not only save us money, it would save us lives. Patients who appear in an advanced state of kidney failure do not do as well as patients who are well prepared for dialysis. They die more. That saves you money, unfortunately, in the world of dialysis.

Mr Jim Wilson: It seems to be the ultimate rationing, doesn't it?

Dr McCready: It's the ultimate rationing is right. There's a published study which demonstrates that patients referred early for pre-dialysis care have about twice the length of survival as patients referred late. So we certainly encourage it.

Mr Jim Wilson: Could you provide us with that study? Would you have that available, or direct our clerk for it?

Dr McCready: I can get it for you, sure.

Mr Tony Martin (Sault Ste Marie): Thank you very much for coming all the way down from Thunder Bay. You'll probably recognize that I also come from northern Ontario; I come from Sault Ste Marie.

I was very interested in your comments about the north and how the north so often gets left out. Certainly we as members of this Legislature make that point on a regular basis to our colleagues and friends. However, in this instance I guess I'm a little perplexed as to what we should be doing in that there were decisions made about northern Ontario by previous governments that we would regionalize our health services, Sudbury and Thunder Bay being the major regional centres, and then out of that we would, as we could afford it, provide services as they're needed in other areas.

Certainly the larger centres in the north are Thunder Bay, Sault Ste Marie, Timmins and North Bay, in my mind, and all of those centres have the resources to do the haemodialysis. Then, if you work out from there, there are smaller centres in all of the regions, places like Kenora and Sioux Lookout, which in fact you had a hand in developing as satellites. New Liskeard, Kapuskasing, Elliot Lake, Parry Sound and Little Current are all other areas that do haemodialysis in the north and offer services to the people in their area. In fact, there is a move afoot to establish three new satellites, one in New Liskeard, one in Kapuskasing and one in Elliot Lake, and also the establishment of a unit in the St Joseph's Hospital in Parry Sound and to expand what is already in Elliot Lake and Little Current on Manitoulin Island.

I know as well that in the last year or so we've introduced to the north the diabetes network that is centred in Thunder Bay and Sudbury, which is spending a significant amount of money not only among the populations that are shared by those communities but also native communities, to do some prevention work in this whole area. I'll be participating in the ribbon-cutting of a brand-new wing to the Plummer hospital in Sault Ste Marie of a renal dialysis unit there that has been developed.

My sense is we're dancing as fast as we can, given the resources and the environment which we're in, to provide as much as we can. I'm wondering what else we should be doing in the north at this time, which communities now next you would target as the ones that are most in need. And given that, as a physician, with the great demand on the medical dollar at the moment and the pressure that's on us as a government to be accountable and responsible in terms of how we spend the limited money we have -- you talked about people being referred or not being referred by physicians for various and sundry, in this instance for haemodialysis, but there are all kinds of other medical needs, particularly in the north, where dollars are required to service people or send them out for specialized treatment. How do we prioritize all of that?

Dr McCready: That's a very difficult question for someone who's involved primarily with kidney disease patients. I would tell you I think that they're of the highest priority, because that's my area of interest. Kidney failure patients have an unfortunate habit of dying if they don't get treated.

Mr Martin: So do cancer patients.

Dr McCready: So do cancer patients, but it takes longer. If you wait six weeks for cancer treatment, that's a big problem, but if you wait six weeks for dialysis treatment, you're dead. It's very plain.

I think that efforts have been made. I don't want you to think I feel that the Ontario governments present and past have made no efforts in this regard. I think they have and I think what's been done has been very effective. But I have several patients who live in a town called Atikokan, which is a two-hour drive from Thunder Bay on the Trans-Canada Highway, or part of the drive is on the Trans-Canada Highway. That's a very exhausting process for patients, to have to drive something like 200 kilometres either way for dialysis. I have four or five patients who live in that town.

I think that when you're looking at setting up satellite units you have to be realistic. You can't set up a satellite unit for one patient in one town. But if we could develop some criteria for the establishment of satellite dialysis units, it would include a minimum number of patients to make it viable, it would include a minimum distance from the nearest dialysis unit, and I think that can be done. One of the recommendations that will come out of this end-stage renal failure task force of the Kidney Foundation will be to set criteria for looking at the establishment of satellite dialysis units.


The one thing I'd like to point out about establishing these -- let's call them alternative ways of delivering dialysis care -- is to point out to you that if you remove the stable patient from the hospital-based dialysis unit and place him in a satellite unit or a self-care unit or an Independent Health Facilities Act or wherever, what you then do is increase the acuity of the remaining patients in the dialysis unit and increase the workload without necessarily someone thinking of increasing the funding. That, I know, is a problem in Toronto, where the better patients have already moved out to satellite units and the sicker patients are in the hospital units.

I don't think you have an answer. That's the point of my presentation, that physicians can't answer that question. The physician is presented with a patient with a problem and he tries to find a solution to it. Society and the government which leads society are going to have to be the people who set these criteria and they're going to have to be up front about them so that people will know what to expect. Patients and their families expect treatment, is what I can tell you.

Mr Martin: Just one quick supplementary to that is, if physicians can't answer those questions such as the question of priority yet physicians are asked to make the referrals that are necessary and you're saying that referrals are screened, how do they make the decisions in those circumstances?

Dr McCready: I don't think physicians make decisions based on resource allocation. They don't say, "I'm not going to send Mrs X because I know the dialysis unit's going to be crowded." They simply know the dialysis unit is very crowded and Mrs X seems a very sick old lady and they fall into the decision of not referring her. It's not a conscious thing that physicians do and it's not all physicians either.

We're trying to explain, I think, in Dr Mendelssohn's presentation and mine, why there's a gap between the US dialysis rate of something like 120 per million of new patients per year and the Canadian rate, which is now about 100. The gap is there. The patients have to be there somewhere or we believe that they are there and that they're simply not being referred and they're dying of their kidney failure.

As a nephrologist, I feel I should be going out and looking for these patients and trying to get them on dialysis, but I need the resources to be able to do that: (a) to find them and (b) to treat them when I do find them.

The Vice-Chair: Ms Sullivan, something urgent.

Mrs Sullivan: Yes, I wanted a supplementary on this particular question with respect to referral from the primary care physician.

What kinds of educational efforts are made through the OMA to the primary care physicians to provide them an indication of when referral should take place so that you are seeing the patients at the pre-dialysis stage?

Dr McCready: I don't believe any efforts have been made to educate the primary care physicians.

Mrs Sullivan: Should there be efforts made?

Dr McCready: Absolutely.

The Vice-Chair: Thank you, Dr McCready, for your presentation. We appreciate it.

While the next witness is coming forward, Mr Gardner wished to speak to his memorandum to you on technical terms.

Dr Bob Gardner: Members will see that I did a short memo on some of the definitions and descriptions of the various forms of dialysis treatment. This material was drawn from the background you got before the hearings, but it was buried among other things there, so I thought this might be a handy reference as we're hearing all of this stuff.

I also, of course, do want to check all of these technical terms with experts before we finally get around to writing the report, and I'll do all that before we go to press, so to speak.

The Vice-Chair: Thank you for that information.


The Vice-Chair: The next presentation will be by Dawn Evans of the Kitchener-Waterloo Hospital.

Ms Dawn Evans: I'm Dawn Evans, the program manager for renal services in Kitchener-Waterloo Hospital. I would like to thank the group for inviting me to attend. Kitchener-Waterloo is in southern Ontario, but we have some very unique problems, different from Metropolitan Toronto.

I've prepared in your handout a summary of what Kitchener-Waterloo Hospital is. It is a community hospital of about 400 beds. It is the only provider of renal services in the region. It is between London, Toronto and Hamilton, and we service a large area in between that. We are a metropolis but we serve a huge rural area, and it is not uncommon for our patients to travel one to one and a half hours each way for dialysis. Unlike Metro Toronto, there's no transit to get them there; they depend on friends and family to get there. So our location is different from some of the other larger centres. We are the only hospital that provides dialysis, so we have to look after our own. When we get crowded and overrun, we have no other hospital that can help us out within a reasonable driving distance, so we have to solve our own problems.

We are between the major centres. We refer to Toronto, London and Hamilton for tertiary care. Our patients wait for their surgery, they wait for their access repairs, they wait for medical referrals until there is a dialysis space in another referral hospital for them to be dialysed.

The pattern that has become very common for our patients lately is that they go in for surgery if it's a minor procedure such as an access revision. Because we are only a community hospital, they go into the tertiary centre for their surgery for their access in the morning, they come back in the afternoon, and they have their regularly scheduled dialysis in the evening. That's pure hell for a patient or his family member who has to transport him, because they're not ill enough to require transport by ambulance, or the timing is so tight that they can't get them back and forth. That's the impact this is having on patients.

We're also very fortunate at Kitchener-Waterloo Hospital: We have a brand-new haemodialysis unit. It was funded in 1990, and we moved into that unit in July 1992. That unit was to last us five to 10 years.

We have made some plans as we go through this process to try and prevent a crisis. We have added an assisted care dialysis unit within the hospital. It was a last-minute addition to our program to try to take some of the patients from the haemodialysis unit. We have closed down our in-hospital peritoneal dialysis unit. It was costly for a few patients and it wasn't felt to be effective for the few we were treating, so we now treat them with a different mode of dialysis.

We have increased the staffing in our CAPD unit to be able to send more patients home on that program. We have added a home cycling program to be able to give patients more options at home to be able to dialyse, especially those rural patients who have that long travel.

Those are the kinds of things we've done as we've moved into our new space and as we've lived in our new space and realized that we're going to be in a major problem very, very quickly in spite of our brand-new unit and a completely renovated floor of a hospital. Our whole program is on one floor now, which has many added benefits, but we're on the seventh floor and we can't expand out. We're going to be in a crisis in a very few years.

If we take some of the numbers that Dr McCready referred to, if we take the low end of the projected growth for dialysis patients at 10% per year, this is where we are and this is where we're going to be in 1996. I've applied that same 10% to the transplant numbers and to the people awaiting transplants on the list, which perhaps isn't accurate, but I thought I would use that same 10% across the board.

We have a brand-new haemodialysis facility and its capacity is 96 patients. If you look at 1993-94, we did 97 dialysis patients, on average, in the last three months of this fiscal year that we've just finished. We're full. We have an assisted care unit that opened a year ago in November. Its capacity is 24. We now have 20 patients in that assisted care haemodialysis unit.

We have funding and staffing resources and operational facilities at this point in time to handle 54 CAPD patients. We're at 68 as we're heading into this next fiscal year. We're in trouble and we've got a brand-new facility, and we have nowhere else to turn to send our patients.

Our treatments, if you add that 10%, increase across the board to haemodialysis treatments, and those are both acute patients and chronic. I didn't separate them out, even though there is a major difference in the acuity and the cost to that. That's a phenomenal number of haemodialysis patients and treatments to be done in a community hospital.

What does this all mean to our patients?

I think too that we shouldn't shield the fact that we help Toronto. Even though we're full, we have little dips in our patient number when we'll dip down to 88, 89, 90, and we do accept patients from Toronto hospitals, primarily from the west end, Mississauga. Credit Valley in particular refers us patients to help them out of their bind. Last year we did 10 patients, for up to three months per patient, to dialyse them in Kitchener-Waterloo. Those patients travelled from Mississauga to Kitchener and back again three times a week for treatment because there was no space in Mississauga. What happened for the three months over October, November and December was that we would send back the patient who had been with us the longest and they sent a new one to replace that patient.


Our physicians constantly liaised with that hospital to try and get those patients back home, because we, as the providers of dialysis in Kitchener, were constantly being asked, "When can I go home?" We were helping out, but we were put in a bind at the same time, trying to help that patient. That isn't right. We shouldn't have patients travelling an hour and a half from city to city to have dialysis.

This is not a patient disease; it is a family disease. When a patient has dialysis many things change for this patient and the family dynamics. When we have no place in Ontario for a patient to go for dialysis, that patient does not go on a holiday. I won't negate Camp Dorset in Ontario -- it's an incredibly wonderful place for our patients -- but it's become the only place they can go for a dialysis. When there is a family funeral, when there is a wedding, when there's a new grandchild, these people are unable to travel, like you and I, to attend these major social functions in their shortened life. That's not right.

They have delays in surgery, and I alluded to that earlier. When they start dialysis, there's no choice in when they will have their dialysis time. They're given whatever time there is to be put on dialysis. We make desperate attempts to work around the workers and give them priority times, but we have people squeezed into spaces that shouldn't be times for dialysis, but that's where they are because that's the only space.

I haven't been here to hear the other witnesses, but something that needs to be stated very loud and clear is the dedication of the nephrologists, the social workers and the nurses in this profession; it's absolutely incredible. They get these patients dialysed wherever they can do it, or I think we'd be in a worse situation than we are.

The waiting list for transplant: If you take those numbers I provided for you and just move those across, one in three patients on our waiting list was able to get a transplant in 1990. That increases every year as the number of patients on dialysis and therefore the number on the list and the wait time increases.

Those are the implications to the citizens of Kitchener-Waterloo Hospital's dialysis program. We certainly service a large number of patients from other areas as well, but that's the impact it has on us in southern Ontario. In my opinion it's not all that different from northern Ontario, but people don't think of us as northern Ontario. In that aspect we're very unique, I believe, in some of our problems. We're full, and that's two years after a brand-new unit and in spite of what we think are some rather heroic ways to try and live within the annual cuts we've been given, to provide service to more patients with fewer dollars every year. Thank you.

Ms Jenny Carter (Peterborough): It's certainly apparent from everything we've heard and from what I've heard as a member in my own riding of Peterborough too that we do have a problem here.

There are one or two things I'd like a little enlightenment on. The previous presenter did mention a woman of 90 who was on dialysis. I was just wondering, how many people over 65 would be on dialysis, what sort of percentage of the recipients?

Ms Evans: I would guess up to a quarter.

Ms Carter: So there's really no limit. I mean, people can benefit from this and achieve a much improved lifespan up to any age limit.

Ms Evans: Definitely, and these patients learn to do their own dialysis at home just as well as the younger people do. They do very, very well.

Ms Carter: We've heard repeatedly about this roughly 10% increase a year that's happening in the number of people now. I wonder whether any studies have been done to see how long into the future this is liable to continue. I can't see that we could have a 10% increase year over year indefinitely. Would you know anything about the projections?

Ms Evans: I don't know about any studies, but I know that Canada has one of the lowest rates per million population of people on dialysis.

Ms Carter: I'm just wondering whether there are any projections.

Ms Evans: I think the projections are that as the diabetics live longer with better treatment and as this baby boom generation comes to age, it will be a worse problem than it is today.

Ms Carter: So we've really got two things: We've got to do something in the present and immediate future, and we have to have plans for the long term as to how we're going to cope with this.

In Peterborough we don't have facilities. People travel mainly, I think, to Oshawa. Of course there are people in lots of different situations, and I've really been struck by the variety of situations people who need dialysis are in. Quite a few of them are managing at home and they have worries such as, "What if my mother, who is helping me out, gets too old to do it?" -- that kind of thing. People have suggested that it would be better if those machines that are being used by one person could somehow be centralized and maybe nurses could be available to help people use them, and so on.

But we did hear yesterday that it is actually cheaper, a better return on the dollar, for somebody to actually have this machine in their own home, because the overheads are smaller and there aren't the labour costs.

I just wondered if you could give us some idea of what you would see as the structure of an improved system for dialysis: How much would be hospital, how much would be centres where people could help themselves, how much would be in the home -- what kind of system we ought to be looking at?

Ms Evans: We're not funded as a home dialysis program for haemodialysis, so I can't speak to that particular mode of dialysis for Kitchener-Waterloo Hospital. What our focus has been and what we're planning with our operational strategic plan is to increase our home peritoneal program so that hopefully it could be 50% of our patient population. Whether that's realistic in the long term -- because as Dr McCready said, these patients fail on peritoneal dialysis and go on to haemo. If we could have that 50%, if we could have 10% of our patients doing assisted haemodialysis and the remaining 40% requiring in-centre haemodialysis total care, that would certainly make our picture a lot brighter.

Mr Jim Wilson: Thank you, Ms Evans, for your presentation. I too wanted to ask a little about in-home haemodialysis, but you've already answered that you're not funded.

One of the things I've heard in the months working on this issue is that it seems to me that within the ministry there's somewhat of an argument going on about: (1) I've heard of hospitals being reluctant to take on dialysis programs, and (2) the costs associated with in-hospital care and the argument about whether it's just too expensive to be adding these programs to hospitals, that perhaps we should be looking at satellites.

You're in a hospital, you're the coordinator of the program. Could you just give us your comments on the services you're providing and whether you think you're cost-effective? This thing, unfortunately, in spite of the lives that are being lost, is boiling down, as so many issues do in this day and age, to money and priorities.

Ms Evans: It's interesting that as I was leaving to come here today I had someone from Guelph General administration call me to see about setting up a haemodialysis satellite program there to service the community of Guelph. So hospitals and citizens in other centres are looking to how they can have this service within their hospital.

There's no question that it's an expensive service, but we do everything we can do within the program and with our social workers and our pharmacists, nephrologists and nurses to keep these people employed, to give them the supports they can get with the least amount of cost to the system. Yes, it's expensive, but it's a really hard thing to measure. How do you measure a quality life? Most of these people would not deny that they're having quality lives and are grateful for the service they receive. How do you put a price on that? Yes, it's expensive, but can you put a price on that? I can't.

Mr Jim Wilson: Agreed. Just as a supplementary, have you heard any arguments -- I mean, I haven't had any hospitals tell me they're opposed to setting up satellites, whether they be in independent health facilities or whatever, to actually take the pressure off the local hospital. For instance, in K-W, would that be something your board administration would agree to, for example, do you think?

Ms Evans: We've decided we will certainly start to look into it with the Guelph General so it can go to the ministry to see whether the ministry would agree to that as a feasible project.

We have had a satellite peritoneal unit in the Walkerton general hospital in the intensive care unit, where they looked after patients from Walkerton who were in our program; they looked after them there. We set up a satellite peritoneal CAPD program in Freeport chronic hospital. They came to us and said, "We'd like to service this patient population." So community hospitals and other hospitals work together to address this need. We do what we can with the community resources, the VON and the other home care resources, to keep the patients home without bringing them into hospital. I think, as a group of people, nephrology workers do that exceptionally well.


Mrs Sullivan: Could you estimate for us the proportion of your patients who would be outside of the normal catchment area of the hospital?

Ms Evans: In the Waterloo region?

Mrs Sullivan: Yes.

Ms Evans: Probably 35%.

Mrs Sullivan: I know that in my community some people would go on to Kitchener, but most of the people from Halton would be treated in the Hamilton area, or possibly at Credit Valley, but I think Credit Valley is pretty jammed these days.

What kind of a network is there that allows you to know, or is there one, where and if there is a space available within a reasonable distance or opportunity for the patient to be served there?

Ms Evans: We just call each other. Manager calls manager, nephrologist calls nephrologist and says: "We have a person who needs treatment. Can you take him?"

Mrs Sullivan: So it's informal and day to day?

Ms Evans: Yes.

Mrs Sullivan: I also wanted to ask what other kinds of services are provided through the hospital, including such things as social work, pastoral care and where and how the community hospital links into, say, the services that are offered through the Kidney Foundation, where the hospital would leave off and the Kidney Foundation or other community services would take over, including in-home support services.

Ms Evans: We have a nephrology social worker, dietitian and pharmacist as part of our team and they are full-time for nephrology. Those three people work with a nephrologist and the nursing staff to refer people to the community resources as they are being discharged. Our social worker also is on the board for the Kidney Foundation, so she has a very strong link to know the patient services provided by the Kidney Foundation and those provided by the community. She's our link to the Kidney Foundation primarily for those types of services for the patients.

Mrs Sullivan: Is the discharge planner for dialysis the same discharge planner as exists for the rest of the hospital?

Ms Evans: It's any one of them.

Mrs Sullivan: Okay.

The Vice-Chair: Thank you for your presentation.


The Vice-Chair: The next presentation will be by the Scarborough Renal Dialysis Working Group. Would you like to come forward please.

Welcome to the committee. Please introduce yourselves and proceed with your presentation and hopefully there'll be time for questions following the presentation.

Dr Robert Ting: I'll start the discussion. I am Dr Ting. I am a staff nephrologist at Scarborough General Hospital. With me are Dr Berry, who is a nephrologist at the Centenary Health Centre in Scarborough; Keith Spiegelberg, who is the executive vice-president of finance at our hospital, who can address questions in terms of the perspective from an administrative point of view. We brought one of our patients in hospital right now, Jagsarran Beechan, who is a consumer, and he can tell you the saga of what it's like to go into end-stage renal failure as a patient in Scarborough right now; and Mary Ann Kneeland, who is the nursing manager of our renal floor at the Scarborough General Hospital. She can address any questions you have in terms of nursing care.

Right now in Scarborough we have a population of over half a million people and we have no long-term renal dialysis facilities. We are totally dependent on transferring our patients to either the downtown teaching hospitals -- Wellesley, St Mike's and Toronto General Hospital -- or on occasion we can send some patients out to Oshawa General, which serves primarily the Durham region but we have sent a few patients out there.

I've been in the States for the last few years. I just finished my training at Stanford University back in November 1993, so I've only come back to the system within the last few months. I can tell you, having gone from one system and seen another, things were bad before I left, but they've gotten much worse since I've come back.

If you were a patient in Palo Alto and you went into renal failure, you would basically come into hospital and you would get started on haemodialysis or peritoneal dialysis -- in most instances haemodialysis, because it's economically more remunerative for nephrologists in the United States, but either way you would get on right away. Basically the spots are there waiting for the patients, not the patients chasing the spots here.

I can speak for what happens right now to someone who goes into renal failure in Scarborough. If they come to see me in my office, basically I try to keep them out of the hospital as long as possible, which is often not in the best interests of the patients. Really, when people go into renal failure, it's much better for them to start dialysis while they're still healthy and to avoid waiting as long as possible, because you want someone who's strong so they can tolerate their dialysis well.

What we do now, though, because of the dialysis crisis, we try to put people off dialysis, try to keep them off and try to manage them medically as best we can. When they do get bad enough -- either they're in pulmonary edema, they can't breathe, they're having chest pain or they're on the brink of death -- we do bring them in the hospital.

When we were coming down today, I was showing David Mendelssohn's article to Jagsarran. He's actually right now on peritoneal dialysis at the Scarborough General Hospital and he asked me, "How come you never mentioned anything about haemodialysis to me before I started on dialysis?" I said: "I didn't even mention it to you because there's no way I could offer it to you. There was really no point in me offering you something that wasn't available to you."

What happens right now, when I admit patients to the Scarborough General Hospital, they get their PD catheter in immediately and they commence peritoneal dialysis, but our problem is we have no PD training program. So it's not unusual for our patients to sit in hospital for three months, sometimes four months, sometimes even longer until they get a peritoneal dialysis training spot at one of the downtown teaching hospitals. We do send some patients out to Oshawa as well for peritoneal dialysis training, but as of January 1994, they had hit their quota for the year up until March 31, so we were told they couldn't train any new people until after April 1.

I think I'm going to turn the floor over to Jagsarran and he can tell you a bit about what he's been through. I've known him since I came back at the end of November. He's still in the hospital right now waiting for a training program. He's been in the system since the end of November now and he can tell you a bit about what he's been through the last little while.

Mr Jagsarran Beechan: I was on dialysis in February when I was at the Scarborough General Hospital. I was waiting to go to Wellesley Hospital for training. I went there and they said they were going to call me back, and up to now I'm waiting. I have to take the bus to and from the hospital six days a week. I have nobody to take me and bring me. I'm not working presently now, and every time I take the bus, I have to put $2 aside. I want to know when I'm going to get training. Why can't I get training at Scarborough General Hospital and not go to Wellesley Hospital? It's not nice to go in the cold weather to and from the hospital. I would like to know if they're going to train me at Scarborough General Hospital, yes or no.

Dr Ting: Do you want to tell them how you felt before dialysis and after dialysis?

Mr Beechan: I'm a changed person now since I have this dialysis. Before, I could not eat. I was short of breath. Every week I had to go to Dr Ting's office and ask him when he was going to send me to the hospital: "I can't breathe. I can't eat. I have burning in my eyes." He said there is no place in the hospital for dialysis. He said, "You'll have to wait until the last stage." I was in a dying stage before they got me in the hospital.

It's not for me alone; there's lots of patients there, I know.


Dr Ting: Right now, we have on our floor, tower eight, 38 beds. Of the 38 beds, about 10 to 11 beds are occupied by patients who really don't need to be in hospital. They're just sitting there to get their peritoneal dialysis done by the nurses because they haven't been trained to get it done yet. Now, I can tell you at Oshawa General, when they do the training, if someone is young, competent and alert like Jagsarran, it would take them less than two days to train this person to do their own dialysis to go home. But here we have young people who are perfectly willing and wanting, but there's a bottleneck in the system. There are no training spots.

So basically you have young people sitting in hospital waiting and waiting and waiting, and I can't think of a more inefficient way of using health care dollars than filling up hospital beds with people waiting to get peritoneal dialysis training.

Dr W. Berry: I would like to reiterate what Dr Ting has said. I've been in Scarborough since 1972 and up until about three years ago I could get my patients downtown without too much of a problem. But over the past three years, the number of patients that I have had to do peritoneal dialysis on has doubled each year. In 1991 I did 10, in 1992 I did 20-some-odd and in 1993 I did over 30. Now, these are not elective dialysis.

As Dr Ting has told you, we try to baby the patient along until we can get them into the program downtown, but when the program downtown is full and these patients can't be moved and you have somebody with shortness of breath, inflammation of the lining around the heart, can't eat, we have to bring them in and start peritoneal dialysis. And as you've heard, it can take 10 to 12 weeks, sometimes longer -- 14 weeks -- to get patients downtown. Meanwhile, they're occupying an active-care bed.

Again, we are not funded for dialysis. We don't have the funding for the training program. We have the staff; we have the space; we could do it. I think basically the two hospitals are virtually the same in their needs. In Scarborough, Scarborough Grace Hospital is also running into problems. In Scarborough, the Scarborough hospitals group have gotten together and we're united in trying to form a regional centre so that all three hospitals can utilize the facilities and have cooperation among the medical staff.

The Vice-Chair: Questions?

Mrs Sullivan: I'm interested in the proposal that you have put before us with respect to a centre for dialysis that would in fact be a system within the Scarborough geographic region. I wonder, first of all, if you could tell us where that is in the system: Has it gone through the district health council and so on; where is it in the process; has it gone through the boards of each of the participating groups and so on?

The second question that I want to ask is to Mr Spiegelberg, and that is what the impact is on the annual operating costs of the hospital of maintaining CAPD patients in-house, in hospital, rather than being able to put them on a dialysis program. Have you done a life-cycle or cost-efficiency analysis with respect to that?

Mr Keith Spiegelberg: With respect to perhaps your first question, the three acute care hospitals in Scarborough, through this working committee, have agreed on various methods of attempting to provide end-stage renal dialysis treatment to our patients. There is agreement by all three hospitals as to how to proceed, which is really quite remarkable, actually --

Mrs Sullivan: It's a first step.

Mr Spiegelberg: -- and entirely due to the cooperation of the medical staff.

With respect to Scarborough General, you have to understand we do not have an approved dialysis program. We have no Ministry of Health approval for the program. We simply don't know what else to do with patients; 10 beds, to us, on that unit is anywhere from $350,000 to $500,000.

Mrs Sullivan: Have the hospitals, as a group, taken the proposal to the district health council, and where has the DHC gone with it?

Mr Spiegelberg: The proposal has not gone to the DHC at this point. The proposal has gone forward to a committee looking at dialysis services in the east end, but the proposal has not gone to the DHC.

Mrs Sullivan: I guess then the PA to the minister should respond: Since we have special-purpose bodies that are in fact looking at the urgent issues in dialysis, is the minister also going to require a re-review by a district health council if recommendations are coming forward?

The Vice-Chair: Would you like to address that question at this time to the parliamentary assistant?

Mrs Sullivan: To the parliamentary assistant. He looks as if he's going to kill me.

The Vice-Chair: Mr Wessenger, do you wish to respond at this time?

Mr Wessenger: I don't think I'm going to be able to answer the question at this time obviously, but certainly, just for clarification, if I just have a supplemental on this. What I'm astounded at is that it obviously would be much more cost-effective for you to have a peritoneal dialysis training program in the Scarborough hospital rather than keeping people in hospital. Is that correct?

Mr Spiegelberg: Yes, it would be.

Mr Wessenger: It would be much more cost-effective for it, I guess.

Mr Spiegelberg: Yes.

Mr Wessenger: You require approval for establishing such a program. I'm just thinking in the short run as distinct from a longer term here.

Mr Spiegelberg: Yes, you see, in-hospital patients -- we can shut down the program. We can treat patients in acute renal failure as required and then simply put them in a taxi and give them a chit to go downtown someplace, but we've opted not to do that. When we start a program, we would prefer to start a complete program that addresses all the concerns of the patient and allows us to provide for that patient on an ongoing basis, and we would need approval for a permanent program.

Mr Wessenger: You certainly have raised a very interesting point. I can see a need in this area for some of the -- it doesn't make any sense what you're doing now, in the sense of keeping people in hospital when they could receive training quickly and be able to do their own self-help dialysis by themselves. It would make much more sense as I can see that, but I'd just like to follow that up too.

There's another issue that was raised that I would like some comment on, and that is the fact that the patients often have no choice. The only choice they're given is peritoneal dialysis. Just from a medical perspective, would you say that more patients are receiving this type of dialysis than ought to receive it? Should there be more patients who ought to be on the non-peritoneal dialysis?

Dr Berry: I think there are far too many patients receiving peritoneal dialysis than should be. Many of them should be on haemodialysis, but when you don't have haemo available and you've got a life-threatening situation, you have to make do with what you have.

Mr Wessenger: Right, and certainly in your area, that's your observation. Fine.

Mr Jim Wilson: Thank you for your presentation. There are just a couple of quick questions. One is to Mr Spiegelberg. I'm sorry I just sort of missed the figure. It's $450,00 or something.

Mr Spiegelberg: It would be $350,000 to $500,000, yes.

Mr Jim Wilson: And you're just taking that out of global budget?

Mr Spiegelberg: That is correct.

Mr Jim Wilson: And no special funding for dialysis from the Ministry of Health?

Mr Spiegelberg: That is correct.


Mr Jim Wilson: I'd be tempted to ask you what had to suffer in the hospital in order to be able to provide peritoneal dialysis, but I won't do that. The decision came, though, if I understand correctly, because there was no sense referring to the Toronto teaching hospitals because of the backlog there, and you were just forced to deal with it. Is that right?

Dr Ting: I think they have such a backlog they can't even handle their own patients, and in a way it's even harder for us now because they're very tight. When they know there are patients on peritoneal dialysis at Scarborough General, our patients are sort of given very, very low priority because they are no longer in a life-threatening situation. They go to the bottom of the list because they're already on dialysis. Yes, they're in hospital and they can't lead a productive life, but they're in hospital and they're being kept alive. So obviously, if there's someone who isn't on dialysis yet, they'll jump ahead of our patients who are waiting for the spots downtown.

Mr Jim Wilson: To me, at least from my perspective, establishing a training program shouldn't be such a big deal and to me it wouldn't seem to cost that much money. Does Mr Spiegelberg or anyone else have a comment on why you haven't been able to do that to date or why the ministry hasn't responded?

Dr Ting: Can I just say something? I think one of the problems with dialysis you have to remember is you really have to be a complete program. You have to offer the whole complement of both renal and peritoneal dialysis really, because patients on peritoneal dialysis can develop peritonitis, they can develop complications from their peritoneal dialysis. If you have a peritoneal dialysis program without a backup system for haemodialysis, every time you had any complication in your peritoneal dialysis patients, you would be in a real -- you really do need the both together.

Mr Jim Wilson: The last question, Mr Chairman, if you don't mind. In Markham in January an independent health facility, a private operation, was opened and it's serving 12 patients. It seems you to me you could use one in your area. Are you wedded to the idea that dialysis service has to be hospital based, or if this committee recommended the satellites and forms of independent health facilities where feasible, would you be happy with that?

Dr Ting: I think the Markham dialysis is probably the way to go but I think you do need a hospital-based patient because as patients are started on dialysis initially, you don't know how stable they are. I can tell you at first hand, because I cover the Markham clinic -- I'm in a group and my partner's actually the medical director of the Markham clinic. We've had to turn a lot of patients in the Markham clinic away, back to the hospitals whence they came, because they're not staffed in a place like that for patients who are the least bit unstable. You really need to have a base hospital where you can send patients if they develop complications and problems.

I think you could have a smaller hospital-based program, but you probably would still need that as a backup because when you have satellite units, patients develop bleeding or they develop seizures or they develop some sort of complication related to their dialysis. They really need dialysis but within a general hospital that's able to look after them.

Mr Jim Wilson: That's very helpful. Thank you.

The Vice-Chair: Thank you for your presentation.


The Vice-Chair: The next presentation will be made by representatives of Dialysis Management Clinics Inc, and that will include, as I understand it, Mr Noel Egguera, who is listed. Welcome. Please introduce yourselves and proceed with your presentation.

Mr Igal Holtzer: Thank you, Mr Chairman. My name is Igal Holtzer from the dialysis clinic in Markham. We'd like to thank you for the opportunity for doing a presentation here.

With me I have Franca Tantalo, our chief executive officer. She's a nurse and she's been in dialysis for over 25 years, so she's got a lot of expertise. Recently -- we're very excited -- she's leaving her current job and she's going to join us full-time to manage the clinic.

Also here is my wife, Carol. She's been in dialysis for many years. She's the president of the company. I report to her. She's been in dialysis for around 20 years. Her main role is in quality assurance, and presently she's got a full-time job at the Sheppard Centre. I'm sure you've heard of the Sheppard Centre dialysis unit. She also has two kids and me, so she's a pretty busy girl keeping the two clinics running.

Also we have Noel, who's one of our patients. We've heard that there are very few patients coming to talk here, so we asked him to come here. We appreciate he took the time to be here.

I just have 10 slides. The main objective here is basically to tell you what is the difference between what we do versus the rest of what you've heard so far.

A little background on the dialysis clinic, which I call DMC. We are a free-standing haemodialysis clinic, which means we are not a satellite unit and we are not a self-care dialysis unit. We are providing a very innovative approach to health care and very much leadership, which coexists with what the Minister of Health is looking for at this time.

We are the first and only haemodialysis unit in Canada. We've been operating for 12 years. We're an Ontario corporation. There are three partners, the three of us, 33% each, and the innovative part over here is that nurses provide the services. We do not prescribe the treatment, as Dr Ting said. Dr Tam is our medical director and he's not a partner there.

Our mission statement when we started in 1982 was to provide haemodialysis for travellers. We started in 1982 with four dialysis machines and 500 square feet, so it's very small. We were open only by appointment, so it was very expensive. But we addressed the issue of travellers, because nobody could have taken travellers in this city, so that's what we did.

All our nurses are very highly qualified nurses. They've been in dialysis for five years, and that's why we have very high-quality care there. We dialyse hundreds of patients through the year, through the 12 years, always with success. Some of those patients are being refused by Carol and Franca. They have their criteria.

We dialyse some Ontario patients, some renegades like Cathy Johnston. She was fighting that if she's allowed to travel around the world, she should have the right to travel in Ontario. She was fighting very hard, together with the kidney foundation, to be able to do that. That's why we're here today, so I'd like to thank her for that.

Some of the trends that we saw through the 1980s, I don't really want to go over it again because you heard about a lot of trends recently, just a couple of things that we came across through the years. One is the transfer of patients from one centre to another.

We got, through the years, a lot of phone calls from patients saying, "Why do I have to be transferred to Kingston to be dialysed when there's a unit here in Toronto standing empty?" We fought for that through the years, and I think now we're at a stage where we can see that a lot of people want to have this service in their own community.

In 1992, because of all those trends, we changed our mission statement. We wanted to provided haemodialysis services to patients in their community maintaining outstanding quality care in a cost-effective manner.

The Minister of Health presently, actually on December 1, granted funding for us for 36 dialyses per week, but I have to say, since we're a private corporation, we are personally responsible for that to the bank. We are servicing 11 chronic patients and one spot is always open for travellers.

Just to give you a little frame of reference from the point of view of costing, at the same time I got a letter from Jim Wilson, a letter that was addressed to you by the Ministry of Health, the funding for Orillia. For this kind of amount of money, we could've opened one unit in Peterborough, one in Scarborough and one in Alliston, with 12 patients each. That's what we could've done. And keep in mind that operating three dialysis units is more expensive than doing just one.


Under the IHF, we got granted the licence on December 1. On December 1 we were working. We used the old clinic, to start working there, and then we moved down the hall to a new location, all new plumbing and everything, within 30 days. Everybody was pretty impressed that we managed to do it so fast. Within 60 days we were at full capacity. Now we have five patients on a waiting list, but we could have more. We just basically cut it off. You can ask Carol and Franca more about that. We really appreciate the doctors' support and the Kidney Foundation in this area.

The one thing you probably can see here is that we really have the true cost. When I submitted a proposal for expansion of our clinic to the district health council, I was told, just like I was told a couple of days ago here, that the cost of running this kind of operation in a hospital is about $50,000 per patient per year. I put the little charts to show you.

Another thing that's very important here, and I'm urging the committee to look into this, is that when we talk cost -- we're a private business. I'm counting here even the cost of the cheques in the bank, the 70 cents we pay to the bank. We're counting the insurance, everything. In a hospital, I was told, they don't count the global budget of the hospital; they're counting it differently. So when you look into it, please look at it very carefully.

Basically, for the expansion we propose, it's approximately half of the cost of doing it in the hospital. With the new DMC, you can see there's a substantial saving there. I'm not trying to cut down the hospitals over here. The hospitals are playing a very important role in what we're doing here. We need the hospitals, as was said today here a number of times. The thing is, we can implement it faster, we can cut the bureaucracy, and we're doing a lot of high-tech stuff in there. We have very specific patients we can get in there.

I don't want to say anything about the patient comments, because Noel is going to talk about this, except that only two weeks ago a patient told me -- actually a patient from Kingston, the last one; she used to be a nurse -- told me that these kind of facilities are 10 times better than being in the hospital in chronic care.

In conclusion, we believe our clients or our patients should not be required to be in acute care in a hospital. They should be in their own community or closer to home. DMC can provide those services in a cost-effective way and we will eliminate some of the bureaucracy by doing so. We believe very strongly that we have the same goal as the Ministry of Health by providing this kind of progressive thinking in the 1990s.

For an action plan, on my last slide, we really have to do something about the district health council. We submitted a proposal there six weeks ago. I was told we're supposed to get an answer in two weeks. It's been eight weeks. I don't have to say any more; a lot of people said things.

Today, we can accept four more patients -- today. We have the facilities to accept four more patients. We have the facilities to accept another four patients in 30 days, but we have to get the funding. You can see that it is very reasonable funding. We would like to open more facilities. We can open in Peterborough, we can open in Scarborough, the same way we opened in Markham. We would be glad to do Alliston too, providing everybody agreed to that.

We urge the committee to look into the true cost of dialysis. You should look at the types of patients that can come to us.

Also, in closing, we would like to invite the committee to our open house, which is on April 28, from 6 to 8 o'clock in the evening. You can come and see. There's going to be wine and cheese and a few other things, so you're invited to come along. Thank you for your time.

The Vice-Chair: Thank you for your presentation. Would Mr Egguera wish to make any statement now before we go into questions?

Mr Noel Egguera: I would just like to reiterate that I used to be in the hospital. I started my dialysis in 1991. I stayed over a year. When I heard that they were opening a centre practically near my place, I grabbed the opportunity. I believe the hospital is for less stable patients. Stable patients don't need to be in the hospital. In my case, I felt better in the centre, and I have more say about my treatment. That's it.

Mr Jim Wilson: Thank you very much, all of you, for coming. I want to extend to Mr and Mrs Holtzer a personal thank you for your assistance and for the tour of your facility. I'd like you to describe, for those people who may not come to the open house and have not visited your facility in Markham, what it's like and where it's located.

Mrs Carol Holtzer: We're located at Market Village, which is a one-storey shopping mall right behind Cullen Country Barns. It provides patients with ample free parking, which is one area that patients coming to Markham have actually saved on. Right, Noel?

Mr Egguera: Yes.

Mrs Carol Holtzer: Patients aren't reimbursed for their parking three times a week in the downtown hospitals. There may be some social assistance there, but where we are, you drive in, you park, you come for your treatment. The patients are very comfortable. If they are travellers from out of town, their families can actually entertain themselves for the three to four hours that the patient is on the treatment.

We have three active haemodialysis stations. One nurse provides the treatment for the three patients, and we have a technical dialysis assistant. So there are always two people on duty at all times.

Located in our facility is also an emergency call button. One push of the button, the security at Market Village phones the ambulance and is prepared at the front door to direct them to where we are. We've used the button once, with great success.

Mr Jim Wilson: Perhaps just so we get our terminology right, when I referred to satellites in my motion before the Legislature on December 9, I want you to know and I want everyone paying attention to these hearings to know that I've tried to use that term in the broadest sense. I note in your presentation that you want to make it clear that you're not a satellite of some other unit, that you are truly an independent facility. However, in my terminology, I rule you into the mix -- I just want people to understand that -- and it's just part of the mix, because you've been quite forthright in saying that unstable patients are not appropriate.

Obviously, if you're looking for expansion, you've got demand. Can you give us some feel for how much of the dialysis problem you can look after through independent facilities? Carol, you've been in the business for many, many years as a nurse. I need a rough feel. Could 60% of patients out there go this way?

Mrs Carol Holtzer: No, I don't think it's that high. It's very difficult, because a lot of patients on perineal dialysis could possibly be on haemodialysis and be part of that stable population if the facilities were available for them.

It would be very difficult to actually say what that number is, because patients first going on dialysis are not necessarily stable. Once they have been on dialysis for a while and realize that it's not as frightening as they originally thought it was going to be, then a lot of them can come out of the hospitals and dialyse in an out-of-hospital setting and feel very comfortable in that setting. But it takes a while for them to be able to get away from having all of this excess personnel around them and this hustle and bustle. It's a security issue for a lot of patients, and it depends on the individual how long it takes them to feel that way.

Our oldest patient in the clinic is 82 years old and he's absolutely delighted to be there, because it makes it very easy for him, to be able to come there. He should be able to come there for a very long time because he's very well otherwise. So it really isn't age-dependent. It really depends on the medical condition of the patient.

We're very selective in those patients. We have sent patients back, without a doubt, if we feel they are unstable or that they will become unstable, for various reasons. Physicians have been absolutely wonderful about taking the patients back and are screening the patients better for that.

But to say exactly how many patients there are, I'm not positive; maybe 25%.


Mr Jim Wilson: Perhaps I'll try the question from a different angle. To make an independent facility such as yours feasible, how many patients do you require to service? The way I look at you, you could be set up in any town. Do you have a magic number, though, that makes it feasible?

Mr Igal Holtzer: You really should have 12. Actually, you should have probably 15 as a backup; in case somebody's going to the hospital, you should have somebody else. Really, the optimal way and what we have right now is 12, but you can go to 20.

Ms Carter: Could the Ministry of Health save a lot of money by using you as a model, by getting some secrets of how you do it?

Mr Igal Holtzer: It's interesting you ask me this question. While we were sitting in the back, Franca and I, I told her that yesterday there was a question to Dr Toffelmire, "What percentage of patients can go on self-care?" and he said 30%. I asked Franca, "What percentage could go into our centre?" and she said 50%; Carol says 25%. Let's say we took 25%. If we go on this chart and we save $20,000 per dialysis patient per year, take 25% of the 5,600 dialysis patients, a rough calculation, you've saved $40 million. Not all of them will go to centres, but this is a calculation we did in the back. But you're not going to get 2,000 patients out of hospitals into those centres, because it's going to create other problems.

Ms Carter: But the secret is having the free-standing clinic.

Mr Igal Holtzer: That's our secret.

Mrs Carol Holtzer: A lot of it, from my perspective, from a nursing perspective, is allowing the patients the control and the freedom to be able to be in their own communities and to have nursing staff who are looking at preventive health care versus an acute care facility. The nurses and physicians at acute care facilities have to deal with the crisis as it develops. They don't have the time. It's not that they don't want to; they would desperately love to be able to teach the people about how to keep out of the hospital. They can't; they don't have the time.

In this kind of facility, because you're not dealing with crisis intervention -- and that's what the hospitals deal with -- you can spend more time on things that will keep them out of hospital and in better health so that, hopefully, the long-term use of the hospital will be different. But it's a very different type of nursing and you can't do that in a hospital, because I've worked in all places.

Ms Carter: You seem to have the ideal facility for what the particular patient requires. You're catering, you say, for about 25%?

Mrs Carol Holtzer: Nobody knows; we don't know. In the United States and many other countries in the world, an extremely high percentage is out of hospital. If you take a place like New Zealand, it's almost totally out of hospital. It depends on the way you look at the system and how you want the system to work.

Ms Carter: I have another question, and this has come up several times already. We're told that in the US, far more people per million, or whatever measurement you want to take, receive dialysis than do here. It was suggested that one reason for this is that maybe we have a higher rate of transplants here than they might do, but I feel we haven't got to the bottom of this yet. I'm just wondering what other factors there might be. Could there be conflict of interest in the States? I understand that this is the exception, that this is the one thing that gets funded publicly.

Mr Igal Holtzer: It's interesting. Carol and I just came back from California and we visited a number of dialysis units there. We heard a number of times through this tour that they are looking now into eliminating the idea that physicians will own dialysis units in the US. You make your own interpretation of that; I'm not going to say why. There's a big panic there in the US now about it. That's recently. Apparently, they're looking to pass legislation January 1, 1995, about it. It's what we heard; we didn't see, but somebody told us about it, on numerous occasions.

Ms Carter: So there could be a problem.

Mrs Carol Holtzer: But you also have to look at the patient population. There are very different demographics of patients in the US than there is in Canada. Certain groups of people certainly have kidney disease more so than other people do. I'm not an expert at that; you certainly have a lot more physicians here who know those things better than I do. Patients get dialysis here, but it may take them a long time and they may be pretty sick by the time they get it.

Ms Carter: But they could be less successful in some way in prevention, in avoiding conditions that lead to the need for dialysis.

Mrs Carol Holtzer: Yes, that's very possible.

Mr Igal Holtzer: I want to quickly point out that we visited some dialysis units in Israel. The story is the same as the US. A lot of people have dialysis much more in Canada.

Mrs Sullivan: I'm interested in the chart that you have included as part of your presentation with respect to the true cost of dialysis. I wonder if you could describe more fully what in fact are the comparators in the chart. You're not including many physician services, laboratory services that would be included in the hospital base costs, I assume, or even in some of the satellite centre costs. You're not including social work costs, which would be included in the hospital base.

I guess what I'm asking you for is a more complete analysis of what these cost comparators show. My own sense is that frequently the private sector can provide a cost-effective delivery of health care services within a public system, but I think it's unfair, frankly, to have a simplified chart that presents an argument that doesn't include all the necessary factors that may well be required for a certain patient population that needs hospital delivery or satellite delivery or whatever. It would be useful if we had additional data that explained particularly how these cost comparisons were arrived at, and I think that would be useful to the committee.

Mr Igal Holtzer: What I suggest is that when I asked a district health council, "How do you arrive at this $50,000 or $47,000 a year?" they could not be very specific about it. This question was going on for 12 years, how much it costs in a hospital. They never come out and say how they get to $50,000. I can provide it, but if you want to do a fair comparison, you have to compare apples to apples.

Mrs Sullivan: What was your original capitalization for the opening of the centre in Markham? What were your original capital costs?

Mr Igal Holtzer: About half a million.

Mrs Sullivan: And your annual operating subsidy from the Ministry of Health now?

Mr Igal Holtzer: It's a private organization, so we'd rather not get into it, but we can get it to you.

Mrs Sullivan: But it is an independent health facility.

Mr Igal Holtzer: Yes.

Mrs Sullivan: And it is a public grant.

Mrs Carol Holtzer: Yes, so you can go and get the numbers.

Mr Igal Holtzer: You probably could get the numbers, yes.

Mrs Sullivan: Okay.

Mr Jim Wilson: It's also a contractual agreement.

Mrs Sullivan: I suppose then we get into the question of the involvement of the private sector and how public that financing is going to be, and I think that's an important question when we're talking about accountability for the spending of funds. I understand that as an incorporated body, probably with limited liability and those other issues, you have competitive factors that you --

Mr Jim Wilson: But if it wasn't a good deal, the NDP would not have signed them up, believe me.

Mrs Sullivan: No, but I think it's useful to have the information.

Are you a publicly traded company?

Mr Igal Holtzer: No, we're not traded. We're a private company, incorporated in Ontario.

Mrs Sullivan: Okay. Good.

The Vice-Chair: Thank you for your presentation. We appreciate it.



The Vice-Chair: The next presentation will be made by Dr Edward Cole of the Toronto Hospital, University of Toronto. Welcome to the committee. Please be seated and proceed with your presentation, however you wish to do it. We have your handout.

Dr Edward Cole: I appreciate the opportunity to talk to you. I'm a kidney transplant person. I know you're focusing on dialysis in a major way. What I hope to do is to tell you how kidney transplantation fits into the global picture, the issues of transplantation versus dialysis, to give you some ideas of the numbers and then say what I think organizations like Parliament might be able to do with respect to this.

As you know, there are two very good treatments for kidney failure. One of them's dialysis; one of them is transplantation.

What would be the benefits of transplantation as compared to dialysis? Transplantation is not a lifesaving treatment. Its difference is not in quantity of life but rather quality of life, so the benefits of transplantation relate to more independence, not having to go to the hospital or, at home, doing dialysis.

There's a substantial improvement in feelings of wellbeing, for lack of a better term, which is the thing that patients appreciate most, and documentation by a number of different groups of an improvement in the percentage of patients who return to the workforce.

Most patients on dialysis are not able to have children, be they male or female, and the likelihood of that is much higher once they've been transplanted and have good kidney function.

There's a significant cost benefit to transplantation as compared to dialysis, and my numbers are very approximate. I'm sure you've gotten much more accurate ones about dialysis, so I don't think we need to argue about it. But if you want to say that dialysis costs $30,000, $40,000 or even $50,000 per patient per year, transplantation has a substantial cost in the first year of about $40,000, but every year thereafter the cost is, say, $7,000 to $10,000. So over a period of time, over a period of a number of years -- the average lifespan of our kidneys is probably in the range of seven to 10 -- at the moment there is a substantial cost saving to the health care system.

The patients do better, they're more likely to rejoin the labour force, and the cost is substantially lower over a period of time.

Suffice it to say, and we don't need to get into this in detail, not everyone is a good candidate for a kidney transplant. People who have significant other diseases apart from their kidney failure are less likely to do well; they are more likely to run into problems. Thus we can't transplant everyone who's on dialysis, but we could transplant a far greater number than we're currently doing.

Just to give you some idea of the numbers, these are data from 1991 and this looks at patients three months after they develop kidney failure. How are they being treated? You can see that we're looking at about 2,600 patients. Some 2,200 of them are on dialysis and about 10% of that amount -- that's only three months later -- are transplanted. So most patients, the vast majority, are treated with dialysis initially. That's really the way it has to be for a variety of reasons that we can talk about later if you wish.

Most of these data are from the end of 1992, and I'll point out where they're different, but they reflect all of Ontario, as did the previous data that I gave you. At the end of 1992, there were about 5,500 patients with kidney failure, about 3,000 on dialysis and about 2,500 transplants. There were 972 patients waiting for a transplant. I'm sorry, but the only data I could get on short notice was at the end of 1993, and people on this transplant waiting list are waiting an average of two years' time.

Finally, if we look at the number of transplants that are being done in the province, I've shown you the last three years, 1991, 1992 and 1993. What you can see from the bottom number is that we've essentially plateaued, although things are up or down slightly.

We do transplants in two ways. Cadaveric donors are the ones who die in a car accident or of a stroke and so forth. They become brain-dead, and if we get consent, we offer their organs. That's the way most of our patients get transplanted. But we're doing more living donor transplantation, in part because there are advantages to it in terms of results and in part because of our shortage of cadaveric donors. We have increased our living donors a substantial percentage, although the number is still small. As you can see, in 1993, of 311 transplants, 240 or so were cadaveric and 72 were living donors.

The key points are that we've got a treatment which in selected patients is better in terms of quality of life and in terms of cost benefit, but we've got restricted access to it, not in the sense of us restricting it but in the sense that more patients could be transplanted per unit time, but we aren't doing that. Our waiting list is growing, and this issue of dialysis overcrowding is exacerbated by the low transplant rate.

The point that was on my transparency at the beginning that I don't think I mentioned is that an additional advantage of renal transplantation is that it's one of the ways in which we get people out of the dialysis unit and create new dialysis spots dealing with the same number. There are basically only two ways for the most part: Either the patient dies or the patient gets a transplant.

Our major problem in terms of transplanting patients is really the supply of cadaveric kidney donors. We looked at this some years ago. The reasons we don't have enough donors are multifactorial. It's clear that the medical team is not doing its best in terms of looking at every patient who dies as a possible organ donor. They aren't doing their best in terms of approaching families.

We probably all don't have the ideal technique in terms of dealing with families in what is obviously a very traumatic situation, because by definition we're dealing with the families of patients who were quite well. They were living, for the most part, pretty normal lives and then, suddenly, they have a catastrophe. The emotional trauma is quite difficult and a physician or surgeon is going from trying to save a life and doing everything he or she can to then asking for an organ. I'm not saying we shouldn't be doing better -- we absolutely should -- I'm simply pointing out the difficulties.

There are still a number of patient families that, for a variety of reasons, refuse to give consent. Perhaps I should leave some of the reasons for the question period, if any of you are interested, but we can get into that.

The final issue is that in order for somebody to become a donor -- let me take a step back. Suppose somebody has a massive bleed into their head and dies. If they die, if they basically lose function and the doctors decide there's nothing they can do, what they'll generally do is they'll often turn off the machinery and then the patient dies, is pronounced dead etc.

What happens with organ donation is that, first of all, they have to keep them on the breathing machine until they can prove that they're brain-dead. They have to go through extensive testing, certification by two physicians. They then have to stay in that intensive care unit, because all of these patients are in that, while they are assessed as donors, because we can't really assess them very well until we have consent. They need to stay for a number of hours. They have to be maintained. They still need the same acute nursing and medical care.

You all realize, I'm sure, that as well as a shortage of regular hospital beds, critical care beds are short. The number of them is in this city has been reduced substantially from what they were some years ago. We're asking hospitals and doctors to keep these patients, for whom can they do nothing, in critical care beds longer.

Number two, there is a cost involved in keeping them in beds longer and in the surgical procedures in terms of nursing etc involved in harvesting the organs. Up until the present time, there's no mechanism for reimbursing hospitals for the donors they contribute. In essence, there's a net negative cost to a hospital in terms of the donation per se. If you're a neurosurgeon who has got a call from Joe Blow, God knows where, who wants to get a patient in who hasn't even been investigated, so you don't know if you can save him, and you've got somebody you are waiting to certify as an organ donor whom you've already decided there's nothing you can do for, it creates a very difficult decision for that particular individual. So there are a variety of issues there that can be addressed.

What can the government do? One of the issues, and I'm sure this has come up in terms of dialysis, is that the life support funding mechanism was a mechanism to allow us to fund as many of these cases as we can do. Our transplant rate is plateauing, but I think it's important conceptually that if we could double our transplant rate, it would be critical for our hospitals to know that they would be able to get the costs covered for that. I think it's as important in its own way in this as it is in dialysis.

Number two, I think we need to continue to foster public education. Many people still don't believe that if their family member is an organ donor, that will not impede their medical care one iota. That's a critical issue as well as the fact that transplantation is not an experiment, and all of the various successes.

I think that the issue of legislation relating to consent in organ donation is one that we could perhaps discuss further, depending on what your interests are, but it's clearly an area where government can play a role.

The issue of funding hospitals for organ donors I think is an important role.


Finally, you may have heard from some of my colleagues earlier about the drugs that are currently funded by the government. One of these is cyclosporine, which has improved our transplant survival rate by 20%. It's made a huge difference. Without this drug, which costs about $5,000 or so a year, the success of our transplants would be far less and the costs and the overcrowding of the dialysis unit would be far more. So it makes sense in purely fiscal terms to continue the funding of this drug.

The threat that was raised a number of months ago, which I hope we've put to rest but I don't know, is really a very critical issue. It makes no sense in any kind of terms to continue.

The Vice-Chair: Ready for some questions?

Mrs Sullivan: Just to start, we have asked for a confirmation from government that the life support funding formula is going to continue, and we hope we get an answer. Maybe tomorrow would be good, but I won't guarantee that will happen. Certainly it's a matter that we feel quite strongly about and I know it's a matter of enormous importance to hospitals that are doing this work.

You talked about several areas of consent that I'm interested in following. With the new consent legislation that is now waiting to be proclaimed, I'm thinking of two aspects of that. One is Bill 208, the living will piece of legislation, and the other piece of legislation is Bill 109, which is the Consent to Treatment Act.

If you have a patient who is in the position of having signed a donor card, and then you have a patient who is technically mentally dead or technically dead I guess but not really dead because he's still hooked up, only for mechanical reasons or only for medical reasons, for the transfer, where does the consent come from?

Dr Cole: Consent comes from the next of kin. It's a good point. What we would use the donor card for is that sometimes the next of kin don't know what the individual would have wanted and they're placed in a very difficult position. If we can show them that the unfortunate individual who's died has indicated previously that he wanted to be an organ donor, then that often influences them in a positive way to agree on his behalf, but basically we do not use the driver's licence as enough of an indication for us to go ahead.

Mrs Sullivan: Presumably, until we had some kind of legal remedy such as a presumption of consent, the power of attorney for personal care, ie the living will, the power of attorney that specifically directs the substitute in a certain way, would be the most positive interim mechanism for you.

Dr Cole: Yes. I must confess that you're probably a lot more knowledgeable about living wills than I am, but I wasn't aware that would impact on organ donation in a major way. I thought it was more related to how far one would go in resuscitating people etc.

Mrs Sullivan: I'm not sure. I guess that's why I'm asking the question. I'm wondering if it would be a tool.

Dr Cole: I must confess that I don't know enough about the living will legislation to know what issues it covers, but neither I nor my colleagues who are also involved in the organ donation issue have ever suggested that would resolve it.

The presumed consent issue: I don't know if you want to discuss it or not, but it's a more complicated issue. I guess what we're moving towards in Ontario is something that says that we'd like to have some evidence that when a patient died, he had the opportunity or his family did for him to be an organ donor. That's really a fairly loose thing, and to the best of my knowledge there isn't any audit that's going to be in place absolutely that is really going to push people into doing this, and it's not all that strong. This leaves it up to the next of kin really.

Presumed consent says that you are presumed to be willing to donate your organs unless you or your next of kin state otherwise. There are several potential problems. There are pluses and minuses. In Austria and in Belgium, it's improved their donor rate extraordinarily. In France, it hasn't worked at all. There are a couple of potential problems with it.

One is that it's been suggested that different societies react differently to the, if you will, loss of individual right to make these decisions and that some feel many people will become more alienated from the system with this. Number two, in France, there was a legal challenge to this which got a lot of play in the press. It's never been ironed out and it hasn't improved their organ donor rate.

The organ donation organization in Ontario, with is called MORE -- multiple organ retrieval and exchange -- has recently commissioned a study looking at how appropriate it would be to draft presumed consent legislation in Ontario. It's not in its final format. It's only in an interim one. Thus far, they are not convinced that it would be beneficial, but a lot of the arguments against it are philosophical; the ones in favour of it are pragmatic. I think it's a matter of opinion. Many of us are more pragmatic. But that's where it stands.

I don't think the transplant community yet knows what it wants, but hopefully it will soon and you might consider getting a copy of this final position paper from MORE. I could certainly direct you to the right place if you're interested in hearing about it further.

Mrs Sullivan: I think they're going to be witnesses and may discuss this issue.

Mr Jim Wilson: Thank you, Dr Cole, very much for your presentation. You were succinct and to the point and did a very good job because, I guess it was a couple of years ago, I thought we saw some light at the end of the tunnel with respect to organ transplants. Frances Lankin, when she was minister, I think had a very sincere interest in the matter. I remember going to many, many meetings around her board table with MORE and I thought, I had the sense, as critic, that the government was really moving on the issue. Let's be fair to the government because it's its turn to ask questions next. Have they moved, have they tried, or are they bogged down for lack of funding, or what's the problem?

Dr Cole: I don't think this government has done a bad job. I didn't know who was on what side, I must say, but I don't think this government has done a bad job with respect to transplantation particularly at all. They certainly haven't done a worse job than the people before them and, for the record, Mr Rae has been very committed to transplantation per se, as well as the party. That isn't what this is about.

Mr Jim Wilson: Okay, but I've been to a lot of meetings where I've heard that and yet as critic I keep getting letters, people saying nothing's improving.

Dr Cole: Well, yes. I think there are two issues: one is whether something's improving or not and two is, can you assign the blame to the government for nothing improving? I think I've raised a number of issues where I feel the government can play a role. I think that if the government threatens life support funding, that's going to be a problem. That has not impacted up until now on kidney transplantation. I think they have fostered public education. I wasn't being critical of them in that role.

Neither I nor my colleagues have perceived government as a barrier. In terms of legislation, as I indicated before, there are a number of different points of view about what legislation would be the best from our perspective and I think we have to wait for that final opinion so they can take some of our direction. I don't think they've been a barrier.

I think the donor funding issue is an important issue and this government hasn't done any more or less than the one before that and the one before that. One of the previous governments, and I can't remember, I'm afraid, which, did ask for our donor costs hospital by hospital, but as far as I'm aware I don't think it did anything with the information. We haven't been asked about that recently, but I think donor funding is an issue. The government of Quebec has recently stipulated separate donor funding, and according to what they say in Quebec, that has made a difference. I think that is an issue government can take up.

I think the threatening to cut off the funding for cyclosporine, in my view, was a potential major blunder, but I must say that when we brought the documented information of its benefit, at least at that point we got the impression that they were backing off fairly quickly.


Mr Martin: I've only had one personal experience of the whole donor process and it was quite a learning experience for me and quite a moving experience to watch the decision being made to donate the organ and then the sensitivity of the doctor involved and all of that.

I wasn't able to ask any questions about a couple of things at that time, which, though, did raise some question in my mind. The word went out that there were some organs available and then we had to wait quite a period of time until we got a response to whether there were potential recipients out there. How much of a problem is that and why is that a problem?

Dr Cole: Understanding that it's difficult to comment on a particular case without knowing all the details, in general, let me say that there are some patients, for example, an unfortunate 19-year-old who's absolutely healthy who dies in a car accident, who has been stable, as it were, even though his or her brain is no longer functioning, has been quite stable, hasn't needed a lot of extra drugs, where one could be reasonably confident that we'd want to use heart, lungs, liver, kidneys, bone. Okay? There are other situations where people have been more unstable, where, let's say, they're 65 or some such thing, and they may have had high blood pressure in the past etc and one needs to take some time to try and understand the details of the case more and offer the different programs these organs.

The timing is such that in terms of things like heart and liver, you have to really be ready to do the transplant when you take the heart out sort of thing, and you don't want to do all of that before. So most of the time, if there's a donor who doesn't have any of these problems, we can decide quite fast that at least we want some of the organs and we work though it. Sometimes the donor's been exposed to a virus, hepatitis virus or something, and it becomes a bit more complicated. Most of the time it's not complicated to decide that we want to use a donor.

There are viral tests that we do on the blood for various kinds of hepatitis, for the AIDS virus, that we have to know the answer to before we can transplant because otherwise we would be passing on a virus which would be creating a disastrous problem, and those can take several hours. When those start may be a bit variable, so that would be another potential delay.

Mr Martin: You talked about the need to do public education around this and certainly funding is always a big issue as well. One of the things that happened, again, in this instance was that your organization, MORE, was recognized as a place a person could make a donation in terms of the funeral. How much money actually comes in through that avenue and is it significant to your work?

Dr Cole: I'm afraid I just don't know the answer to that. I'm involved more by virtue of my involvement in transplantation; I'm not a member of the board nor involved in them that intimately, so I just don't know the answer.

Mr Martin: One other question, then: There was some reference yesterday to some experimentation being done in the area of mechanical organs being available and also there was a mention of kidneys from pigs. Where are we at with that?

Dr Cole: I think where we're at is that aside from whatever one thinks of the ethics, which I don't think this is the time or place to get into, there is ongoing research in this area of organs from animals. We're a long way away from being able to successfully do those. It's definitely possible in the future, but it's not going to happen next year or two years from now or whatever.

The Vice-Chair: Thank you. Ms Sullivan, did you have a --

Mrs Sullivan: Yes, I had a supplementary; I told the Chairman it was a supplementary but it's on a totally different subject.

The human resources planning in all areas of health care is fraught with difficulties and usually, when we find that there are problems in adequate resources, we find that human resources aren't very far behind. If there were an incremental number of transplants, would we have the adequate human resources in place to ensure that needs were met, and with the new planning or with the new directives that are being put into place with respect to medical training, are we ensuring that we are in fact training the specialists required for transplants?

Dr Cole: I guess it would depend on how big an increment. If I told you that we could double our transplant rate and have enough human resources, I'm sure what you would say is, "Then you're wasting a lot of our money by having far more people than you currently need."

If we increased our transplant rate by 5%, yes, we'd have the human resources to cover it, if you mean doctors and nurses and the ancillary people. But if we increased our transplant rate by 30% or 40% or 50% or more, we absolutely wouldn't because even our nurses, who are supposedly on an 8-to-4 or whatever you want to call it schedule, are working a lot longer than that every day. So no, there would definitely have to be an increment in the funding for human resources because in this, maybe more than many other areas of medicine, the doctor is only one of the very large numbers of individuals who are critical to the success of these programs. So no question about that.

The second thing is that you need to spell out for me what you mean by "new directives" in medical education. If you're talking about licensing requirements, I don't --

Mrs Sullivan: No, I'm talking about admissions to medical schools.

Dr Cole: I don't think that the primary purpose of most medical schools is to train people to do tertiary or quaternary care medicine, which is what transplantation is all about. We have tried to modify our curriculum, an area that I've been involved with, so that we include transplant-related issues, donor-related issues and the importance of those things so that people will be aware of it. But I think that if the government continues to cut the number of specialty or subspecialty residency positions that are available, then you're absolutely right that we won't.

I don't think in terms of medical school issues that I could necessarily say there'd be a problem, but I think there's always going to be a requirement for a variety of individuals in this province and country, and not all the programs are fully staffed around the province. I think if one continues to cut the funding to these positions, then there will be a problem, not only with transplantation but with all areas of kidney disease, absolutely.

Mrs Sullivan: Thank you. I very much wanted to get that on the table.

The Vice-Chair: Anyone else?

Mrs Yvonne O'Neill (Ottawa-Rideau): Mr Chairman, I just wondered how many hours we have used to this point.

The Vice-Chair: We'll advise you shortly. Anything else? If not, thank you very much for your presentation.

Dr Cole: You're welcome. Thank you.

The Vice-Chair: The standing committee on social development stands adjourned until April 18 at 3:30 pm.

The committee adjourned at 1807.