STANDING COMMITTEE ON
COMITÉ PERMANENT DE
LA POLITIQUE SOCIALE
Tuesday 14 February 2006 Mardi 14 février 2006
Consideration of Bill 36, An Act to provide for the integration of the local system for the delivery of health services / Projet de loi 36, Loi prévoyant l'intégration du système local de prestation des services de santé.
The Chair (Mr. Mario G. Racco (Thornhill): Good afternoon and welcome. We will resume our clause-by-clause consideration where we left off yesterday. Before I ask the NDP to move the motion we were left at -- I think it's page 17 -- I want to inform you that there was a motion today that extended the hearings until tomorrow. Tomorrow we will be starting at 10 a.m., until 1 p.m., so there will be that addition.
Mrs. Elizabeth Witmer (Kitchener-Waterloo): I just want the record to show that I think we've come in here in good faith, hoping we would have ample opportunity to debate all the amendments we have received from those who took the time to make presentations to us. Unfortunately, we are still continuing to receive some amendments from the government. So if there has been any delay in the work of this clause-by-clause committee, I think part of it is because the government has not had their amendments ready to provide us with. I would just like the record to show that, because we have been ready to go since yesterday.
The Chair: Just for the record -- I appreciate your comments -- both the government and the NDP, as I understand it, provided additional motions yesterday. Today, my understanding is it's the same. There are a few that both parties are going to introduce. Having said that, I thank you for your comments for the record.
Ms. Martel: Thanks, Mr. Chair. Before I move the motion, I want to express my thanks on the record to Mr. Halporn, legislative counsel, who has been working overtime to try to prepare our amendments. He let us know late Wednesday night that he would not be able to get all the amendments ready for Thursday by the 5 o'clock deadline, which is why I asked the clerk to send a note to everybody saying that we would continue to put forward amendments as he finished them, and that's what we have tried to do. I wanted to put on the record my thanks to him for his incredible, difficult work over the past couple of days.
"(5) The Lieutenant Governor in Council shall make regulations prescribing conflict of interest policies and rules for the members, directors, officers and employees of local health integration networks."
Members will see that this comes under the section in the bill, page 7, that talks about the regulations the Lieutenant Governor in Council has an ability to put forward. They involve the LHINs: amalgamation, dissolving, dividing LHINs, changing the names etc.
The reason I have put into this section specifically a reference to conflict-of-interest guidelines is because in another section in the bill it talks about the minister in conjunction with an individual LHIN developing those conflict-of-interest guidelines. My suggestion is that the conflict-of-interest guidelines should be the same for all LHINs, for all members, for all employees etc. That should be done for all of the 14 at the same time and it should be done through a process of consultation, as is outlined in sections that carry on further about having to be posted on the Gazette etc.
I think if you're going to have a standard set of conflict-of-interest guidelines that apply equally to everybody, the way to do that is to have that done by the LG for all 14 rather than having the minister, in discussion with each individual LHIN, develop what may turn out to be different policies.
Ms. Kathleen O. Wynne (Don Valley West): Just to say that in subsection 8(8), because the discussion in each case will be with the minister, we believe that's adequate on the development of conflict-of-interest guidelines.
This is an amendment that was requested by the Council of Academic Hospitals of Ontario, plus the Ontario Hospital Association. If the people in this room were to adopt this amendment, it would enshrine the achievement of the purpose of the act, as set out in section 1, as the overarching object of the bill. The objects should be consistent with the purpose, thus providing a rationale for the objects. It also provides further standards by which the LHIN board can exercise its powers and provide a guide as to which decisions are in the best interests of the LHIN.
This was an amendment requested by the GTA/905 Healthcare Alliance. As written, they believed that the objects currently are not focused on improving health care in Ontario or on improving the health status of Ontarians. These four proposed additions to the objects of the bill would establish optimising health status, improving timely access to health care services, and increasing the quality and outcomes of health services in a LHIN. They believe that is just as important as the achievement of any efficiencies within the system.
Mrs. Witmer: I move that clause 5(b) of the bill be amended by adding, after "needs of the local health system," "based on the population size and population characteristics in the area of jurisdiction of the local health integration network."
Again, this was an amendment put forward by the GTA/905 Healthcare Alliance. It was really encouraging us to take a look where people live. There is currently no model for how the health service needs of a LHIN will be determined beyond consultation. If this amendment were to be adopted, it would ensure that population size and characteristics are taken into account as one of the factors during the planning stages.
Ms. Wynne: I see this as a clause that would actually restrict the planning capacity of the LHIN and would preclude some of the cross-LHIN planning and communication that needs to happen. So I won't be supporting it.
Ms. Martel: I move that clause 5(c) of the bill be amended by striking out "community input and consultation" at the end and substituting "consultation with and input from, at all stages of decision-making, the community, including but not limited to, equality-seeking groups."
Over the course of the public hearings, we heard the concern from many presenters about how the community was going to be involved in the decision-making process. While this appears as an object of the LHIN, I have expanded it so that it makes it clear that input has to be sought from the community at all levels of decision-making, and that input has to be sought from the broadest possible community, particularly those who are the most vulnerable, who have the least say in the health care system and whose needs we have to look out for. I might make reference at this point to those who are consumers or survivors of mental health services, for example.
Ms. Wynne: I don't disagree with Ms. Martel that we heard a lot about community engagement. We're going to be bringing amendments to section 16 that will elaborate on what we mean by community engagement.
Again, this was requested by the Ontario Hospital Association and the Council of Academic Hospitals of Ontario. There was some concern that there was a need for this amendment to ensure the support of the academic health science centres and recognize that they are the building blocks to innovation, and also to make sure that the value of teaching and research is recognized.
"(h) to undertake and participate in joint strategies with the following organizations to improve access to high quality health services and to enhance continuity of health care across local health systems and across the province:
"(ii) agencies, health care registries and other persons or organizations with a provincial mandate that relates directly to health care and that is endorsed by the ministry, including the Cardiac Care Network of Ontario;
"(i) to co-operate with other local health integration networks, health service providers and others to support health care research and knowledge creation, to identify and disseminate information on best practices and to promote knowledge transfer among local health integration networks and health service providers;
The addition of "high quality" was requested by the Ontario Hospital Association, the Council of Academic Hospitals of Ontario and the Cardiac Care Network because they wanted this to become an object of the legislation. The Cardiac Care Network wanted to ensure that the amendments here would mean there was going to be inter-LHIN coordination and provide an obligation for LHINs to work with the ministry-endorsed province-wide organizations such as the CCN. It was really focused on promoting inter-LHIN coordination. That is the reason for this amendment.
Ms. Wynne: I appreciate the intent of the amendment. The LHIN objects already require them to work with provincial programs. Our problem is that focusing on cardiac care is too narrow a focus. A number of groups came to us who were interested in having their program identified, and I think that's not the way we're going to be able to go.
"(m.1) to develop strategies and to co-operate with other local health integration networks, health service providers and others to support the training of future health care professionals and health human resources planning and education;
"(m.2) to co-operate with other local health integration networks to ensure that improvements in access, integration and the coordination of health services do not restrict or prevent an individual from making choices about his or her own health care;
This is a request again of the Ontario Hospital Association as well as the Ontario Long Term Care Association and it acknowledges the importance of developing and training health human resources and commits the LHINs to support that much-needed training. Also, it speaks to the need to state as an object of the legislation the maintenance of patient choice in accessing health care.
The addition of clause (m.3) establishes as an object of the legislation the standardization of the LTC placement process. It is hoped that that would limit confusion for both applicants and their families and allow for some stability in the placement process during the consolidation of the CCACs to match the LHIN boundaries.
Ms. Wynne: Just to say that there are a number of motions for which this is an issue; that is, part of this motion is a provincial responsibility and we have to recognize that not all responsibilities, obviously, are being put into the LHINs. So (m.1) and (m.3) are still provincial responsibilities and, most appropriately, would not be in this legislation.
This actually flows out of the amendment that I had before, that 5(m.3). Again, this would give the minister the power to set the centralized standards for long-term-care placement processes, as enumerated. It would ensure a degree of stability of LTC placements during that consolidation of the CCACs to match the LHIN boundaries. It would limit confusion for the applicants and their families. It would allow for customization at the LHIN level through the local processes.
Now I'm going to make a few comments. This has come under section 6 of the act, which outlines the power of the LHINs, and that's probably the most appropriate place for it to be mentioned. That whole section lists the many things they can and can't do, and it should be appropriate in this section to make it clear that they cannot apply competitive bidding to any of the health sector that they are going to be responsible for under this bill.
A couple of things: We heard from many groups during the course of the public hearings about how chaotic and how destructive competitive bidding has been as a process in home care. Here are but a few of those concerns.
Number one: Because there were so many changes in contracts as a result of the RFP process that is inherent in competitive bidding, many clients -- indeed, thousands of clients, even in the last two years alone -- have experienced significant disruption in their service and significant changeover in their service providers. We need to remember that these clients have an intimate relationship with their providers. They're coming into their homes. They're doing housekeeping. In many cases, they're bathing them. These are not links and attachments that we should be having upheavals with every time there's a change in a contract, which is what has been the case with competitive bidding. So it's had a major negative impact on many thousands of clients across the province.
Secondly, major negative impacts on health care workers: Competitive bidding has resulted in a driving down of wages and salaries of workers in this sector. I remind members that this is a sector where employees are already very low-paid, especially those who don't even have the protection of a union. What has happened under competitive bidding is that the wages that were already not very good have been driven down; people have lost mileage; people have lost a benefit plan; people have lost a partial or a full pension plan; people are paid per visit now instead of by the hour.
There have been many very negative changes, and I think we heard that most clearly and most articulately from Madam Lebrun, who made the presentation in Ottawa, although I should point out that there was also a second presentation by a second PSW at the end of our hearings, a Toronto worker who was very articulate in this regard as well. These changes in home care have essentially been done on the backs of these workers who have lost wages and other benefits as a result of companies trying to drive down their costs in order to get bids.
Third, there has been a very significant shift in the sector from home care being delivered by not-for-profit organizations to for-profit. Competitive bidding has come at the expense of small, community-based, non-profit organizations that had a niche in home care and have now lost that niche. Indeed, that was pointed out to us during the course of the public hearings in references to a 2001 report that had been done by Doran and Doran at the U of T. That report showed very clearly that before competitive bidding was imposed by the Conservatives, only 18% of the providers of home care were for-profit providers. By 2001, that had shifted to over 48% of the providers in home care being for-profit providers. In 2006, I suspect, that's well over 50% to 55%. Not only is that a very significant shift, what it means is that money that should be going into patient care, into direct delivery of home care services, is instead being diverted to the profits of those for-profit companies. Surely, the government, as it talks about its commitment to medicare and its commitment to publicly funded, publicly accessible health care, should be worried about that very significant shift to for-profit agencies and the potential for a similar shift in the broader health care sector that will be under the responsibility of the LHINs.
Now, the minister said the following in his opening remarks, and I want to put this back on the record. I'm quoting from his remarks to the standing committee, January 30, 2006, when he was outlining what he alleged were myths that were being raised by a number of people who had concerns about the bill, the critics of the bill. Here's what he said: "Local health integration networks are going to extend the competitive bidding model to the entire public health care system." He went on to say, "Well, I don't want to seem repetitive, but I'm holding the bill right here ... and, as I've said, I have read it many times. Folks, it doesn't say that anywhere.... LHINs are designed to better manage and coordinate health care services in order to ensure better access to those services. That does not mean competitive bidding."
I challenge the minister, as I have challenged committee members before when we've talked about competitive bidding and when government members have said there's nothing in the bill that talks about competitive bidding. If you want to prohibit competitive bidding, then you put it in the legislation. You make sure that a process that has been so destructive in home care is not permitted to be applied to the other sectors in health that the LHINs are going to be responsible for. We know what those sectors are. If you mean what you say, which is competitive bidding is not in the bill, it's not going to be used, and if the minister means what he says, that is, that competitive bidding does not apply, then we put it in the bill and we make it clear that LHINs are prohibited from using competitive bidding in any shape or form. That's why it appears in the section under the powers of the bill, and I think it's time to do what is right and make sure we cut off at the knees the same kind of destruction and chaos that we saw through home care.
It is very regrettable that through the process that the minister instituted with Elinor Caplan the end result was not that competitive bidding would now be banned in home care too. It should have been. There is more than enough evidence to show why it doesn't work, how destructive it has been and how much money is being diverted from patient care into the profits of for-profit companies. The government didn't do this with respect to home care, and it should have. You now have an opportunity to make sure that this is not extended. Frankly, if the minister means what he says about the Canada Health Act and about Bill 8 and about ensuring the system is publicly funded and publicly accessible, then the committee members will vote today in favour of my amendment to prohibit any further extension of competitive bidding into any other health care sector.
Ms. Wynne: I just want to begin by saying that I appreciate the number of times this issue came forward, and I certainly appreciate the impassioned presentation by Ms. Martel. As the minister has said, there is no expansion in this bill of the competitive bidding model that is in place right now in the province, the one that the community care access centres are engaged in. This bill doesn't envisage an expansion of that.
The reason that I won't be supporting this amendment is that what the minister does envisage is that there will need to be a healthy competitive process among the non-profit providers of health care. If you look at the provision of services around our wait-time strategy, there may very well need to be a competition among the not-for-profit providers of those kinds of services. What we don't want to do is put into the bill something that's going to squelch that kind of process. I won't be supporting the amendment, although I did hear the concern from many of the presenters. If I believed that what this bill was going to do was expand that process, then I wouldn't be in favour, but I don't believe that's what the bill envisages. I do believe there needs to be a healthy dynamic among the not-for-profit providers, so I won't be supporting the amendment.
Ms. Martel: In response, let me make it clear that the bill is silent on how the LHINs are going to acquire, obtain, receive or provide services in the sector. That's the whole point. The bill says nothing about how services that LHINs are responsible for are going to be acquired. What I want to do, and what I think this committee should do, is shut the door in the face of the process being used as one of competitive bidding or managed competition. That's the dilemma. It's true that the bill says nothing about competitive bidding being the model the LHINs are going to use; it also doesn't prohibit them from doing that. So instead of remaining silent on this issue and waiting to see what's going to happen, we should be moving now to shut that door, to slam that door shut, especially given everything we've seen in community care access centres and in home care, and especially given what we heard from front-line providers during the course of the public hearings.
Your minister says that there's nothing in this bill that's going to result in more privatization. I have to tell you that that's exactly what competitive bidding did in the home care sector. The study that was done by U of T, even in 2001, made that clear. So if you don't have a prohibition in this legislation that stops LHINs from acquiring other services in the same way, you're darn right you're going to have more privatization, absolutely, because that is what the result has been in home care alone. You don't want to apply that to other sectors, because you don't want to see that chaos for patients, that disruption to home care workers and that shift to the for-profit sector happening in other sectors of health care as well.
The problem is, the bill is silent on how LHINs are going to obtain services. I am not going to take the minister at his word when he says, "Well, it's not in the bill, so it's not going to happen." The way you guarantee it's not going to happen is to have it clearly articulated and clearly stated in the bill, very directly, under the power of the LHINs, that they will not be allowed to use this model to acquire or obtain those services that they are given funding for to purchase or provide. That's the way we shut this down. The way to make it very clear is to have it in the legislation. If the minister means what he said at the committee, that "I don't see competitive bidding anywhere here," then the minister should have it explicitly in the bill in this section. I encourage the government members to vote in favour of this amendment and ensure that there will be a very clear prohibition for the use of this model in other health care sectors that LHINs will be responsible for.
Ms. Wynne: Actually, I think I've said what I need to say. If clinical services are delivered by publicly funded institutions, not-for-profits, and if there is the need on a particular issue -- provision of cardiac services or joint replacement or MRIs -- to look at our wait time issues and the need for a dynamic among those organizations to determine where the capacity is, then the process of competitive bidding could be used among those public providers. We're not going to close the door on that process, and so we won't be supporting this very general amendment.
Ms. Martel: If I might, just to follow up, the bill doesn't even limit it to the examples that you're outlining, Ms. Wynne. You've given us some examples of where competitive bidding might be required, and you're not going to vote for the amendment because in those cases competitive bidding might be necessary. I disagree that competitive bidding should be the way. Even if it was the case that you were only referring to those sections, that's not explicit in the bill either. The bill is entirely wide open to say that this is not prohibited, not just in the cases you've outlined but not in any case. There is no prohibition whatsoever, and there is no reference to the use of competitive bidding as you've described it in those circumstances that you've just given to the committee. There's nothing in the bill that reflects that.
Ms. Wynne: I will say finally, and I won't engage in further debate after this, that I think there is a need to look at our track record in terms of how we have done since we've been elected in terms of protecting public health care: passing Bill 8 to ban two-tier medicine; repatriating the MRI clinics from private clinics into the public sector. We told the Copeman clinics that the private clinics are not acceptable. So I think that we have demonstrated our commitment to public health care, and that is our track record. I'm going to stop at that.
Ms. Martel: Just in response, and then I'll finish up as well: Look at the track record of this government with respect to competitive bidding. The Conservatives brought in competitive bidding. Your government had an opportunity to end it. You had Elinor Caplan do a report on competitive bidding, but she wasn't even given an option to look at ending competitive bidding. Her option was to try and streamline it or fix it or tinker with it to make it better.
We heard presentation after presentation from people who are living with the experience of competitive bidding in home care now. You should have shut that down when you were elected. You should shut it down now, and you're not going to do that. What we heard during the course of the public hearings should convince anybody, but particularly the government members, that competitive bidding is wrong. We should shut it down in home care, and we should shut it down now.
On the track record that you have, the one you forgot to mention was the track record of continuing to support competitive bidding in home care. It has been a disaster. You should have ended it, and you should end it now.
"6.1(1) A collaborative board is established with the number of members to be set by the minister, with an equal number of members representing all local health integration networks whose geographic areas cover any part of the city of Toronto and members representing the city of Toronto.
"(4) In exercising any of its powers with respect to services operated by or with funding from the city of Toronto, a local health integration network whose geographic areas cover any part of the city of Toronto shall consult with the board.
"6.2 In exercising any of its powers, a local health integration network shall establish and maintain partnerships with other local health integration networks and with health service providers that do not receive funding under subsection 19(1) as the network considers appropriate."
As you know, I'm putting forward this motion because the previous motion that I had put forward to create one LHIN for all of Toronto was not accepted. There's a huge concern on the part of the city of Toronto because there are five different LHINs. There is a concern that the levels of health, provision of services and funding may be quite different. They want one board created, which would ensure that all LHINs that share responsibility for parts of the city of Toronto would work together in collaboration. It would also mean that the board must be consulted prior to any of the LHINs making a decision affecting a part of the city of Toronto. What they would hope to achieve is some maintenance of standards across the entire city as far as the service delivery is concerned.
Ms. Wynne: Just to say -- and I spoke to this issue previously -- that there are other places in the province that have issues similar to the city of Toronto's and that there are health providers other than just the city's that deliver services across LHINs. There is already provision in the bill that requires that there be inter-LHIN communication, so I won't be supporting this.
This is the section of the bill that talks about the members of the LHIN boards being appointed by the Lieutenant Governor in Council or essentially appointed by the government. I am suggesting that "appointed by the Lieutenant Governor in Council" be taken out because, in amendments that will follow, I will propose a system for election of the members of the board versus appointment by the government.
We had a wide range of views about this matter, a number of people who came forward to say that if the LHIN boards of directors were truly accountable, then they would be given their place through some form of an election instead of an appointment by the government. The appointment by the government makes them accountable to the government and not to the communities they are purported to serve. The change in section 7 that's being proposed here would be followed by other amendments that would require an election of the LHIN board of directors.
Ms. Wynne: I'm going to continue to support the public appointment process for the LHIN boards. The government continues to be ultimately responsible, and during the hearings I think we talked a lot about the need for specific representation and expertise on these boards. So I won't be supporting this amendment.
"(1.2) Every local health integration network shall provide to the minister the names of at least one and at most three nominees for appointment to each position on the board of directors of the network and the minister shall forward the names to the Lieutenant Governor in Council.
"4. The network shall ensure that there is a written description of the nomination process that is available to the public before the network begins to follow it and that the description is available on request by the minister or any member of the public.
"(b) the degree of local representation on the board of directors and the need for knowledge and experience of the communities located in the geographic area of the network, including an understanding of local health issues, needs and priorities."
There was a lot of concern about the way in which people are appointed. Some people wanted them to be elected to the network. We heard from the Ontario Hospital Association, Sick Kids, Yee Hong, the GTA/905 Healthcare Alliance, the Association of Municipalities of Ontario, and many of the individual representations that were made all spoke to this issue. What we're trying to do here is establish a process for the selection of board members in order to ensure they're representative of their community, that they do reflect the linguistic, geographic, cultural and gender makeup of the community. It's believed that if they do, they're going to make more appropriate decisions on behalf of their community. Also, people need to be appointed based on their skills and knowledge of health care.
What we have been forgetting in health care recently, to a large degree, is that all our wait times are focused on adults. We're really not paying a lot of attention to paediatric care. Hence the inclusion of that particular recommendation: that at least one person on the board have a background in paediatric care so that we don't neglect our children.
This speaks to the selection criteria and a process for appointment. These amendments would ensure that the local community is well represented, that people have skills, expertise and experience, and that the call for nominees would precede the nomination of candidates for the appointment to the boards.
The other thing is that not all the criteria here would be appropriate for every LHIN with respect to the community that they're meant to serve. Because, as Mrs. Witmer has acknowledged, the need for experience and appropriate skill is what we're looking for, we're going to support the public appointment process that's already in place. I won't be supporting this amendment.
"(1.1) The members of a local health integration network referred to in subsection (1) shall be elected by residents of the network's geographic area in accordance with the regulations and shall hold office for the term specified in the regulations."
As I said earlier, I am quite confident that, under an election process, people with the qualifications, the expertise and the experience needed to make the kinds of decisions that LHIN boards of directors will make would rise to the surface. I am absolutely confident about that and do not see the need to have it done by an appointment in order to guarantee that. I'm also quite confident, since I see any number of people who make application to sit on boards in the health sector, that many people would come forward if the opportunity were granted to them to actually run.
If the LHIN boards of directors are going to truly be accountable to the community and not to the minister who appoints them, the way that we guarantee that is to actually have them elected by the those who live in the area that they are supposed to serve with respect to the LHIN boundaries.
The amendment here would make it very clear that there would be a process for an election that would be developed by the Lieutenant Governor that would apply to all LHINs, to make it very clear that boards of directors will be accountable back to the community, because they will be elected by the community they are supposed to serve.
Ms. Wynne: I'd just like to make the point, and I made it a number of times during the hearings, that in putting this legislation forward, we are trying to learn from the other jurisdictions in the country that have moved in this direction. The experience of other provinces has been that having elected boards has not worked. There are provinces now that are moving to appointed boards because the people whom they need to serve on these boards in this important capacity have not been stepping forward. So that's why we're putting this process in place.
Ms. Martel: Just a short point that I want to make. I find the contradiction between what the government is prepared to do with the CCACs and what the government is not prepared to do with the LHIN boards of directors very curious. It was a former Conservative government that essentially took over the CCACs, that got rid of a requirement for those folks to come from the community, for the chair and the vice-chair to be elected by other CCAC members, got rid of the provision that would have allowed CCAC boards to actually hire their own executive directors, and the government took all that on through an appointment process. Now, in this legislation, we have the situation where the government is saying, "That needs to change, and we need to go back to a situation where, under the Corporations Act, people can buy a membership and they can come to a CCAC meeting and they can elect members to sit on the CCAC board, and those members, amongst themselves, will be allowed to elect a chair and vice-chair and that board will be allowed to hire its own CEO." The government is prepared to do that with respect to the CCAC boards but not with the LHIN boards. I find that contradiction very interesting, and I don't understand it.
Mr. Robert Maisey: Yes. It's Robert Maisey, legal counsel with the Ministry of Health and Long-Term Care. No, there were no direct elections. The district health council members are appointed by cabinet.
The Chair: I would prefer -- I am as flexible as you want me to be. There is a motion, and that's what we should be addressing. Okay? Therefore, if you will allow me to do my job, I would prefer to concentrate on the motion in front of us now.
The Chair: As I said a few minutes ago, I don't believe that we are dealing with the amendment which is in front of us. I would appreciate your assistance. I would remind all of you that it's Valentine's Day. I have a problem at home already because I'm not at home, so don't give me more, please. The wife, and properly so, wants to go out tonight, and I can't.
Again, this is on behalf of the city of Toronto. They just are concerned that there's no requirement for a LHIN to somehow engage the local community. I think reference was made to the fact that the minister likes to say that community members can pick up the phone and speak to board members, but that's pretty unrealistic. So they're looking for a formal process to be established to ensure that LHINs hear directly from the community, and this community advisory board would be one way that LHINs could hear from and respond to local needs.
This amendment has been requested by the Ontario Long Term Care Association. As written, the legislation calls for each LHIN to make its own conflict-of-interest rules in consultation with the minister. This amendment would require the conflict-of-interest rules to be made in consultation with the minister and also in accordance with the regulations; the minister will be given the power to make regulations regarding conflict-of-interest rules. This is necessary to enhance the transparency and ensure a consistent approach to governance of the LHINs across the province. Conflict-of-interest rules, then, would be the same for all the LHIN boards across the province. This amendment and the next one would make it a reality.
This is a reference to a previous amendment that would have had the Lieutenant Governor in Council develop the conflict-of-interest guidelines so that they were the same across all LHINs, versus the current process, which will now be undertaken, where each LHIN has the opportunity to develop those with the minister, which I suspect will lead to different guidelines across different LHINs. The reference was to a previous section, and it was already voted down. So this is either out of order or I will withdraw it now, because the other amendment that it was related to has been voted down. I'd like to withdraw it.
Again, a concern on the part of the Ontario Long Term Care Association. This would give the Lieutenant Governor in Council the power to create rules around conflict of interest and would enhance transparency and ensure a consistent approach to governance of the LHINs across the province.
"(a) financial, personal or other matters may be disclosed of such a nature that the desirability of avoiding public disclosure of them in the interest of any person affected or in the public interest outweighs the desirability of adhering to the principle that meetings be open to the public;
"(h) negotiations or anticipated negotiations between the network and a person, bargaining agent or party to a proceeding or an anticipated proceeding relating to labour relations or a person's employment by the network will be discussed;
"(i) litigation or contemplated litigation affecting the network will be discussed, or any legal advice provided to the network will be discussed, or any other matter subject to solicitor-client privilege will be discussed;
"(k) the network will deliberate whether to exclude the public from a meeting, and the deliberation will consider whether one or more of clauses (a) through (j) are applicable to the meeting or part of the meeting.
"(6) A local health integration network shall not exclude the public from a meeting before a vote is held on a motion to exclude the public, which motion must clearly state the nature of the matter to be considered at the closed meeting and the general reasons why the public is being excluded.
The overwhelming provisions that are here -- there's one small change -- come from Caroline Di Cocco's private member's Bill 123, Transparency in Public Matters Act, 2005. Some members of this committee -- Mr. Craitor and I -- were involved in the public hearings around that bill and there was much discussion among the committee members about how and when meetings should be open and those restrictions with respect to closed meetings. Almost all of the provisions here, with the exception of a small piece, relate directly back to that bill. There was, as far as I remember, pretty well unanimous agreement on the bill after the public hearings.
Mr. Leal: I thank Ms. Martel for bringing this forward. I think it's a very worthy amendment. It's something I would encourage my government colleagues to support. I come from a municipal background and it really reflects the provisions often reflected in the Municipal Act between when you hold open meetings and meetings in camera, in caucus. This is an important amendment and I stress that my colleagues on the government side should support it.
Mr. Kim Craitor (Niagara Falls): I, too, congratulate Shelley. Something I personally believe in is openness and transparency. I did it on city council and make every effort up here. I love the wording. I'd like to see it applied to a lot more boards and agencies as well. I'm certainly going to support this and I'm confident that everyone will support this, so congratulations.
The Chair: I was encouraging Ms. Witmer to say something, too. Okay, it's still on the floor, I understand. If there is no more debate, I'm ready to ask the question. Those in favour? All are supporting it, so it carries.
"11.1 Every member, director, officer and employee of a local health integration network shall comply with any conflict of interest policies and rules prescribed by the Lieutenant Governor in Council under subsection 3(5)."
"12(1) The board of directors of a local health integration network shall appoint an auditor licensed under the Public Accounting Act, 2004 to audit the accounts and financial transactions of the network annually.
"(a) the minister may, at any time, direct that one or more auditors licensed under the Public Accounting Act, 2004 audit the accounts and financial transactions of a local health integration network; and
It is intended that LHINs would be required to undergo an annual audit by a licensed auditor and the office of the Auditor General would retain the authority to conduct audits when necessary. These were suggestions from the Auditor General.
We had a lot of discussion yesterday. The aboriginal community obviously had some concerns about the process in developing Bill 36 and the fact that they felt they were more than stakeholders. There should have been government consultation.
This one would require LHINs to keep and report on data with respect to Aboriginals so that we can be sure they will not be forgotten as the LHINs set out to reorganize the delivery of health services in the province.
Mr. Wood: I wonder if I could speak to this, please? On looking at the original motion tabled by Ms. Witmer, I realized that it might be more appropriate to relocate the wording in the existing subsection 13(3), which deals with contents of annual report, rather than having two subsections dealing with contents of annual report. I wrote a motion by hand to accomplish that, to preserve the existing wording of subsection 13(3) and to add to it the wording that was in Ms. Witmer's motion. So there's no difference in substance between the motion that I wrote out by hand and what was originally --
We heard during the course of the public hearings, and we know from the bill, that the LHINs will develop their local plans based on the provincial strategic plan. The problem was that during the course of the hearings we didn't get very much information about the provincial strategic plan: how it is being developed, who is involved in that process and what will happen once it's developed. It seems to be at this point being done behind closed doors in a manner that it is not accessible to the public.
So the amendment makes changes that would require the minister to actually have some public consultations on the provincial strategic plan; that those public consultations shall certainly include funding to LHINs and other matters that the minister considers appropriate, but that that plan should also take into account human resources in the health care sector; and that the result of all that work and the actual provincial strategic plan that results should be made available to the public at large in the venues that are outlined in that amendment.
Ms. Wynne: There was comment about the provincial strategic plan, and I know there is a conversation about what the process will be to establish that within the ministry and within the minister's office.
The concern is that setting up the consultation process in the legislation at this point could reduce flexibility in terms of finding best practices through consultation for the provincial plan in an ongoing way. So I won't be supporting this amendment.
Again, there is a concern that this amendment would require the minister to include a province-wide cardiac care plan as part of the overall provincial strategy for health care, really encouraging the minister to engage province-wide organizations, not just the CCN, in developing the provincial strategic plan.
Ms. Wynne: Mr. Chair, we're going to be bringing an amendment that will require the minister to consult with province-wide planning organizations. So I won't be supporting this, as I think this is too narrow because it restricts it to CCN.
"(1.1) The provincial strategic plan shall include, as priorities for the health system, health services, including addiction services, for the physical and mental health of patients and the obligation that the ministry and the local health integration networks are jointly responsible for ensuring that those services are available."
I would like to stress that it is absolutely essential that the provincial strategic plan include provisions on mental health and addiction services to ensure that they are included at all times. Given the March 2005 CAMH study showing that mental health and addiction is a particularly vulnerable service sector, this statement confirming their importance ought to be included in this legislation. I just want to read from their presentation a part of their response to Bill 36. They say on page 2:
"A recent review by Ontario health system researchers found that as decisions about funding are devolved from a central governing structure to regional decision-making bodies" -- which are the LHINs -- "there was greater likelihood of mental health and addictions funding being lost" -- it's very frightening -- "due to a predominant focus on physical health needs."
So wherever we have the opportunity -- and I know yesterday my amendment to better define health and include mental and physical health was rejected -- the importance of mental health and addiction services must be explicitly recognized somewhere in the legislation, as these services are essential for the health of Ontarians. However, they just are often forgotten.
Ms. Wynne: The fact that we have for the first time in a decade, in 11 or 12 years, put money into mental health really speaks to our commitment to mental health. I think we had the conversation yesterday about using a broad definition of health, so I won't be supporting this amendment.
Mrs. Witmer: Just for the record, I think it's absolutely essential that we correct the record. Our government did undertake a huge review of mental health services. In fact, we actually had the opportunity to receive an award for our contribution, an international award, based on the work that we did in mental health, so there has been work ongoing. Regrettably, I don't think that ministries of health and governments always put as much focus and attention on this issue. This is just a reminder that we've got to have it there somewhere.
"(b) shall ensure that the centralized means by which concerns related to long-term care may be brought to the attention of the ministry is continued and that each local health integration network take all appropriate steps to ensure that concerns related to long-term care are referred to the ministry through these means; and
"(4) The minister shall set out in a document the process that the minister will use in developing a provincial strategic plan and shall make copies of the document available to the public at the offices of the ministry.
"(5) In developing a provincial strategic plan, the minister shall consult health system users, including patients and consumers, and service providers and have regard for maximizing timely access within each local health integration network high quality health care services.
"(6) In developing priorities and strategic directions for the health system and the local health systems in the provincial strategic plan, the minister shall seek the advice of province-wide health planning organizations that are mandated by the government of Ontario and aboriginal peoples."
Now, these amendments have been requested by the Ontario Long Term Care Association, Yee Hong, the Hospital for Sick Kids, the OHA, the GTA/905 Health Care Alliance, Cardiac Care Network, the Noojimawin Health Authority and others. Basically, again, they want to maintain central standards for LTC providers while at the same time allowing LHINs to develop specialized programs at the local level based on local needs.
Experiences in other provinces, by the way, have shown that when you devolve accountability, as we're doing here, there are variations in basic programs and that doesn't always suit the public well. In 2005, the provincial auditor in Alberta questioned the variations in basic LTC programs offered in that province through the local health authorities. The result is that now, the Alberta government having learned that they need to go back, the Alberta Ministry of Health and Wellness has now restated its role in setting province-wide standards. We can learn from that.
Also, if you take a look at Monique Smith's report, 2004, on long-term care, she recommended a central direction for a renewed compliance program. Let's listen to Monique, whom I do respect very much. Let's take a look at Alberta, who recognized they made a mistake and corrected the mistake, and let's make sure we do have these province-wide standards in place.
Access to services: again, common barriers to accessing health care. According to a survey of older Chinese Canadians, that's really important for those people who do not speak the language and have different cultural programs. Again, we need to take into consideration the needs of the cultural minorities that live outside of the LHIN's geographic boundary.
Also, we need to improve coordination within the paediatric system and address the inequities and weaknesses within the current system. We need to better address the health care needs of children. As I've said before, we're really ignoring these young children.
The legislation currently does not state the process by which the minister shall set out to develop these strategic plans. So we are trying to ensure that the needs, the concerns of all people, including aboriginals and First Nations, are adequately provided for in the LHINs, and that's what this amendment reflects.
Ms. Wynne: I know my friend Monique Smith will be pleased to know that you're referring to her report. But I think that a significant part of this amendment actually should be in long-term-care legislation, as opposed to this legislation. There are also other pieces in terms of the relationship with the aboriginal peoples that we're bringing forward in another amendment. So I'm not going to be supporting this amendment, although I understand that Mrs. Witmer is trying to get at some specificity that I think just isn't appropriate in this piece of legislation.
"1. An aboriginal and First Nations health council to advise the minister about health and service delivery issues related to aboriginal and First Nations peoples and priorities and strategies for the provincial strategic plan related to those peoples.
"2. A French-language health services advisory council to advise the minister about health and service delivery issues related to francophone communities and priorities and strategies for the provincial strategic plan related to those communities.
"(4) In developing priorities and strategic directions for the health system and the local health systems in the provincial strategic plan, the minister shall seek the advice of province-wide health planning organizations that are mandated by the government of Ontario."
I had said that we would be bringing forth an amendment that would require the minister to set up these councils to allow him to get advice on priorities and strategies for the provincial strategic plan from the aboriginal, First Nations and French-language communities. This addresses some of the suggestions that were made to us by those groups. This amendment also adopts some suggestions from the Cardiac Care Network in the broadest way, in terms of mandating that the minister consult with those province-wide health planning organizations so that their planning process is caught by the provincial strategic planning process.
I made reference to this yesterday when I was moving amendments with respect to aboriginal people. We should have all by now received a letter from the Chiefs of Ontario and the Union of Ontario Indians, saying that the amendments the government is putting forward that affect First Nations people are not acceptable to them. This is one of the two that they have already indicated are not acceptable, and I find it regrettable that the government would move forward with an amendment that First Nations peoples and the organizations that represent them have already said is not acceptable to them.
Ms. Wynne: Could I just say -- I think I did address this to some extent yesterday -- that I know the minister has had a number of meetings with the First Nations groups, and this is the amendment that has come forward to us as a result of those conversations. I understand that the groups are not completely happy with this amendment -- I hear what Ms. Martel is saying; I understand that -- but as a result of the conversations with the First Nations groups, this is what has come forward, and I know that there will be an ongoing conversation between the ministry and the First Nations and francophone communities.
Ms. Martel: Sorry. I think it's important to say this is what's coming forward from the government. This is not what's coming forward from aboriginal organizations. We all have a letter in our possession, dated February 9, from the Chiefs of Ontario that makes it very clear they have seen these amendments and have told the government the amendments are not acceptable. So the government chooses to bring the amendment forward, which the government has a right to do, but it comes forward without the support -- indeed, it comes forward with the opposition -- of First Nations organizations in the province.
Ms. Wynne: And that is regrettable, but what I had intended to mean was that as a result of the conversations that the minister has engaged in, these are the amendments that have come forward, yes, from the government.
"15. (1) Each local health integration network shall, within the time and in the form specified by the minister and in consultation with the community of persons and entities involved with or served by the local health system, develop an integrated health service plan for the local health system and make copies of it available to the public at the network's offices.
"(3) The integrated health service plan shall be consistent with the purposes of this act, a provincial strategic plan, the funding that the network receives under section 17 and the requirements, if any, that the regulations made under this act prescribe."
As I moved in an earlier amendment with respect to 14, the intent is to try and broaden those issues that will be dealt with -- in this case by the LHIN and in the former case by the minister -- as a local strategic plan is developed. Those important issues include not just "a vision, priorities and strategic directions," but "(b) human resource adjustment planning" at a number of levels. Those things should be taken into account by the LHINs in a formal way through consultation when they develop the local plan.
"(c) a statement as to how the network proposes to exercise its duties and powers under this act and the regulations made under it, including strategies to integrate the local health system, in order to achieve the purpose of this act;
"(d) a statement as to how the network proposes to measure its performance in achieving the purpose of this act, including objectives and targets for the local health system, and when these objectives and targets will be met;
"(e) a financial plan, including a statement of how the network will allocate resources to meet the network's priorities, objectives and targets for the local health system and to meet provincial priorities;
"(h) a plan to ensure local access to such services as are prescribed by the minister having regard to the population size and population characteristics in the area of jurisdiction of the local health integration network."
This is requested by the Ontario Hospital Association and also by the GTA/905 Health Care Alliance. Unfortunately, the legislation, as currently written, provides little detail on the required content for the integrated health service plan that is to be developed by the LHINs. Given that the IHSP will be the basis for community consultation and integration decisions, it is critical that this section be as precise as it possibly can be. Thus, it should include statements on how the LHIN proposes to meet its responsibilities as well as the needs of the community, how it will spend its money, how it proposes to measure its performance, how it will support provincial programs that we've talked about, and the impact the plan will have on providers, research, education and human resource planning. This would meet those objectives.
Ms. Wynne: I appreciate the detail in the amendment. I think the intention of the plan is that it would be a strategic plan, so some of the things envisioned by this amendment actually wouldn't be part of that kind of high-level document. So I won't be supporting this.
"(2.1) The integrated health service plan shall include, as a priority for the local health system, the requirement that the local health integration network ensure the promotion of the mental health of the population within the geographic area and the provision of high-quality services for patients with mental illness and addictions in the area."
Again, it's from the Canadian Mental Health Association, CAMH and the Ontario Federation of Community Mental Health and Addiction Programs. I very strongly support the recommendation that the provincial strategic plans must include provisions on mental health and addiction services to ensure that they are included at all times. I've told you why I feel so. We just have to remember that this is a vulnerable sector, and we need to confirm that the needs are going to be addressed.
"16(1) A local health integration network shall engage the following persons and entities about that system on an ongoing basis, including about the integrated health service plan and while setting priorities:
"(2.1) Despite subsection (2), a health professionals advisory committee established under that subsection shall include at least one representative of approved agencies within the meaning of the Long-Term Care Act, 1994.
Again, this is coming from Bloorview MacMillan Children's Centre, CCN, OHA, city of Toronto, Ontario Long Term Care. It sets out a definition of community as including the people who need to be included. It speaks to the need for province-wide consultation to engage public health experts in planning. It sets out, as I say, the principles for community engagement. It establishes the membership of the health professionals advisory committee.
What this does is recognize the multicultural and multilinguistic nature of communities across the province with which the LHINs will be consulting. It addresses an issue that was raised by a number of groups in the hearings.
"(c) a community advisory committee consisting of, at a minimum, seniors, mental health consumers and consumers of community support services and, with respect to each of those classes, representatives of organizations that advocate for the interests of the class.
"(b) if the class of persons that the committee is required to consist of is typically represented by a certified bargaining agent, invite every trade union that is a certified bargaining agent for that class in the geographic area of the network to select persons who shall be appointed to the committee."
We heard a lot of concern during the course of the public hearings about consultation and where the LHINs would get their advice. The legislation as drafted talks about the LHIN being required to get advice from a health professionals advisory committee, which is appropriate, but doesn't go much further than that -- at least before some of the amendments today.
It's my sense and my feeling that there should be some other committees that could be established that would also be required to request input/advice from the community with respect to decisions that the LHIN wants to make or other advice they need in terms of carrying out their work. So we've specifically added an advisory committee that would consist of front-line health care workers, who, as we heard during the course of the public consultations, desperately need to be involved in processes where change is anticipated. They are the ones who are on the front line, providing care, and have a wonderful contribution to make in this regard; and we should be talking to a broader range of representatives from the community at large who are neither health care professionals nor working in providing care but those who are recipients of that care in that geographic network.
I have outlined "at a minimum, seniors, mental health consumers and" those who use community support organizations, again with the intention that the LHINs could add others but, at a minimum, representatives from those classes and/or organizations who advocate for them should be on an advisory committee. It's very clear that the LHINs, under the legislation, are going to have some quite significant powers that the minister has granted them. They should be in a position to get the broadest possible advice from those who shall be affected, because they're delivering the service or because they're recipients of the service.
The intention is to make sure that there isn't just one advisory committee made up of health professionals but two others from where that advice, information and input could be solicited on an ongoing basis.
Ms. Wynne: The next government amendment actually suggests a process for community engagement that's broader, that isn't quite as specific. As I look at this amendment from Ms. Martel, there are some very specific suggestions, but it doesn't give the LHIN the flexibility it needs to set up the appropriate advisory committees for its community. So I won't be supporting this amendment.
This amendment responds to the numerous comments we got from groups. Most of the groups agreed that there needed to be more specificity in the bill about what we meant by "community engagement." The challenge was to put in some specific comments without tying the hands of the LHINs. We believe that this amendment does that. It's a non-exhaustive list and definition of what we mean by "community engagement."
Ms. Martel: Part of the effort in the previous amendment that I put was to ensure that very specific groups that are primary users of the system or those who have had to struggle to access health care services would have to be included, that there would be a requirement. We know, because we heard from the many seniors' organizations that came before us, that they are primary users of the health care system and that is going to continue. Secondly, we heard from numerous groups that represent those who access mental health services, or survivors, that mental health is a poor second cousin. It has to fight very hard to compete for dollars and for any kind of recognition in the health care system. Throughout this whole process, if we were going to ensure that their voices didn't get lost, we had to do something very specific to ensure that they would be consulted.
I differ with the government in terms of the amendments as they've been placed. My concern is that there is no requirement under the government amendment for a LHIN to actually ensure that there is a senior on their advisory committee, that there is a consumer of mental health services. That is not defined, and that is why I said very clearly in my amendment that each of these classes at a minimum should be represented. The LHIN can have other patients who have other experiences, but at a minimum, surely we should be protecting some of the prime users of the system and some of those folks whose voices have traditionally been lost when they've been trying to access some of these services; that is, both seniors and those who are accessing mental health services.
I also included community organizations because we heard from very many of those during the process, organizations that represent people who use Meals on Wheels, home care etc. That is a broad cross-section of the community and somebody from that section should as a requirement be providing advice; if not a consumer then at least a representative from a community-based organization that delivers those important community-based services, different from hospital services.
Mrs. Witmer: Given that this is the only opportunity we have to speak to this particular issue of community and community engagement, it's the best that we have, so I will be supporting it. I don't believe that it is ideal and I would support many of the comments that have been made by Ms. Martel.
Ms. Wynne: I'd just like to make a comment. It's interesting: In the area that I represent, there are already seniors who are starting to get together to form a group and they're going to be very active in their participation in the LHIN. There are groups that aren't that active, and I think this amendment leaves the door open for the local health integration network to determine the groups that need to be represented. Youth, for example, have not been talked about a lot in these hearings because they didn't come and speak to us, because they're not necessarily organized in the same way that seniors are. But that doesn't mean that they don't need to have a voice at the table and we don't need to make sure that they're included. I think having a more flexible, more open-ended and clear process is the way we should go. That's why this amendment is being put forward.
"(2.1) Each local health integration network shall establish a physician advisory committee consisting of persons that the network chooses with its geographic area as representatives of legally qualified medical practitioners in Ontario.
This amendment has been specifically requested by the Ontario Medical Association. They did appear before us. This would address the fact that at the present time there is no specified role for physicians to provide independent input despite the fact that they are involved in all aspects of the health care system. This provides a role to allow them to be involved in the management organization of the health care system. Unfortunately, the health professionals advisory committee is insufficient to respond to the request made by the doctors.
Again, I would just take you back. In Alberta and British Columbia they have learned on their own personal experience that there was a failure when they were not able to directly engage physicians. It resulted in a less than perfect process. We have an opportunity to be proactive and learn from the BC and Alberta experience.
Ms. Wynne: Could I just comment that when the physicians came before us, we did talk about the need for there to be a multidisciplinary health advisory committee, and I think that remains my position, certainly in terms of what would be best in terms of advisory for the LHINs.
Ms. Martel: I move that subsection 17(1) of the bill be amended by adding at the end "and may consult a local health integration network and the community of persons and entities involved with the local health system for that purpose."
This section refers to the funding that will be made available to the local health integration networks to provide services within the LHIN geographic boundaries. The current wording that appears in the bill is that the minister may provide funding to LHINs on the terms that the minister considers appropriate. The rationale for the amendment is to also afford the opportunity for the minister to actually have some consultation with both persons and entities in that LHIN about what is an appropriate level of funding for that particular LHIN.
Ms. Wynne: I don't think this amendment is necessary. The minister is going to get guidance through consultations on the provincial plans and the LHINs when they submit their health service plan, and he can seek advice as he needs it. So I don't think it's necessary.
Ms. Martel: I guess the problem is that we don't even know what the structure of the provincial strategic plan is right now. What consultation is going to be involved? Who's being consulted? Who's participating? We have had absolutely no information about the development of the provincial strategic plan through the course of these hearings, so I don't know what the minister's going to ask people to provide him. I don't know who's going to be asked. I don't know who's going to participate.
The provision, as it stands here, is not a requirement, but it does give him the opportunity to request input, at least from those who live in the LHIN area, about what financial resources they think are required to provide services in that area. I don't know -- none of us know -- what the mechanism is for consultation, input or requests for funding or funding levels at this point, because we haven't been given the details of the provincial strategic plan. That may well not be taken into account. There may not be a public forum, a public process, for questions and issues of funding to actually be dealt with by the community at large.
Ms. Wynne: The point is, though, that the minister doesn't need this section in this bill to be able to talk to whomever he chooses to speak to. That's what I mean. I don't think it's necessary. The idea is that the planning process is from the bottom up, so that the LHIN process will inform what goes on provincially. So I just don't think it's necessary.
"(2) When determining the funding to be provided to a local health integration network under subsection (1) for a fiscal year, the minister shall reinvest savings generated by the local health integration network in the previous fiscal year in that network, for the network to spend on patient care in subsequent fiscal years in accordance with the accountability agreement.
"(4) The minister shall ensure that a document explaining the criteria, formulae and other data and considerations that are used as the basis for determining the level of funding provided to each local health integration network under subsection (1) is prepared and that the document is updated whenever there is a change in the basis for determining the level of funding to the local health integration networks.
"(6) Without limiting the generality of subsection (5), the minister shall take such steps to ensure that members of the public can access each version of the document referred to in subsection (4) from the ministry and from each local health integration network."
This ensures that the minister keeps the savings within the LHIN that achieved them, and it provides an incentive for the LHINs to look for efficiencies that they can reinvest in patient care through enhanced or expanded services. They should not be penalized for being efficient. It also requires that the minister set out in writing the basis for funding decisions with respect to LHINs, and that these plans must be available to the public and updated annually.
I think this is important. We really need to make sure that funding decisions -- as the government likes to say, there's a need for openness and transparency -- can be appropriately addressed during consultations with the public.
Ms. Wynne: What this amendment would do is remove the minister's discretion. I think what's necessary is that the consideration -- as the legislation is written now, the minister can consider reinvestment but has to consider that in the context of the government's financial situation. I think we need to leave that flexibility in place and leave the responsibility for that with the minister. So I won't be supporting this amendment.
Mrs. Witmer: Throughout the course of the debate on this bill and since the introduction of the bill, we've heard a lot of people say that this legislation gives tremendous power to the Minister of Health. It is beyond anything that we've ever seen in Ontario, and I think the comments I've just heard from Ms. Wynne certainly confirm that. I guess we want to make sure that there is efficiency within the LHINs, otherwise you're going to have what happens in every other organization: People are going to spend the money, and it might not be spent wisely. This is taxpayer money, and I think we need to take a look at if you have savings, you can use it to improve patient care.
"(2) When determining the funding to be provided to a local health integration network under subsection (1) for a fiscal year, the minister shall not treat any savings from efficiencies that the local health system generated in the previous fiscal year as a reason to reduce funding for the fiscal year in question."
This follows from the previous amendment that was moved by Mrs. Witmer. I decided to move this amendment as a result of a presentation and a discussion I had with the Ontario Association of Community Care Access Centres, which came before the committee and said that they were very supportive of section 17 of the bill, because from their perspective it meant that any savings that were realized could be kept and reinvested in the LHIN. I asked them very specifically where in the legislation, in subsection 17(2), it said just that. The reality is that there's nothing in subsection 17(2) that says that the minister will allow a LHIN to keep the savings it has generated and have those savings in addition to a particular amount of money that he or she -- that is, the minister -- was going to provide. On the contrary, the section is broad enough to also have the minister deduct the amount of the savings that have been realized from an amount of money that he or she proposed to provide to a LHIN in a fiscal year.
The amendment I'm moving makes it absolutely clear that the minister will not have that discretion, that indeed if a LHIN has savings in a fiscal year, those savings will be used by the LHIN, they will be given to the LHIN, and they will not be deducted from a global amount of money that the minister might have provided to the LHIN in the fiscal year. The amendment makes it very clear that if there are savings, they go to the LHIN, and the minister cannot deduct those savings from the funding that he or she would have otherwise provided to the LHIN in the fiscal year.
Ms. Wynne: What this section in the bill does is allow for the possibility for the minister to adjust after there have been savings realized. It's interesting, in the hearings, there's been an inherent contradiction. On the one hand, there have been people who have said, "We're not happy with the LHIN structure because it takes away control from the Ministry of Health," presumably because people were arguing for the status quo; on the other hand, there have been people who have said that there's too much control in the hands of the minister. I think what we're trying to do is write a piece of legislation that recognizes that control of the financial well-being of the health system in the province rests with the minister. That is the minister's responsibility. So we need to have in place enough of a framework that will allow the minister to make those final decisions and hold on to that discretion and at the same time have the local planning process in place. That's why I won't be supporting this amendment. We're trying to find that balance.
Ms. Martel: Subsection 17(2) certainly talks about "adjust," but it can be an adjustment upward, so you get your global amount of money and your savings, or an adjustment downward, so you get your global amount of money minus the savings that you achieved. To be clear that this exercise is not about cost-cutting and the government saving money from the health care budget, I would think the government would want to make it clear that any savings that have been achieved by a LHIN would be reinvested in health care. Otherwise, it's very clear -- the concerns people have raised -- that this bill and the powers in it are all about cost-cutting and finding savings that the government can use from health for other purposes. Many people came forward and said, i.e., to balance a deficit before the next election.
If you want to make sure that the Ontario Association of Community Care Access Centres was right in its support, you would want to make a change to make it very clear that the minister retains funding, because the minister of course will set the global amount of money that is provided each year. He or she continues to have the ability to do that. That's not restricted. The restriction is ensuring that any savings that are realized won't be deducted from that global amount of money that the minister still has the discretion around in terms of determining what it is that will be provided every fiscal year.
Ms. Wynne: Just a final comment. There are other factors in this. There's an accountability agreement. There's a plan that the LHIN has put in place, so that the savings and what happens to those savings are in accordance with what's in the accountability agreement and what the longer-term plan is. I think those are the checks and balances, and I'll end it there.
The purpose of the amendment is to ensure that those who live in a geographic area serviced by a LHIN are made aware of the exact amount of money that has been transferred to a LHIN in a fiscal year. It is public money and the public is entitled to that information. This amendment would make it clear that the amount of money that has been transferred from the ministry down to the LHIN is available publicly to those who would want to access that information.
Ms. Martel: From staff perhaps, if you don't mind. I apologize, I don't know what motion that's coming forward talks about accountability agreements, so I'd like to know what the reference is to be sure that that does say that the amount of money will be published; not just the terms and conditions in the agreement but what the amount is. I just don't know where that is, so I'd like to see it, please.
Ms. Martel: And that the amount of money will be made public through the publishing of the accountability agreements. I don't know where that reference is, so I'd like to be clear that that's the case, so then I know that my amendment is redundant.
Ms. Tracey Mill: I wouldn't say that. Tracey Mill, director of the LHIN legislation project, Ministry of Health. In clause 18(2)(d) is the requirement for a plan for spending the funding of the network to be included in the accountability agreement. Then in subsection 18(5) there's a requirement for the accountability agreement between the minister and the LHINs to be made public. Then there is a proposed government motion, 122a, that would require that the minister and the LHIN establish a public website and publish on those websites any documents, any plans, agreements or anything that is required under this legislation.
Ms. Martel: That responds to information that has to be publicized. If I can go back to clause 18(1)(d), it's the information that has to be made public that I'm interested in. So when it says "a plan for spending the funding that the network receives under section 17," we should assume that that will clearly outline all of the spending that the LHIN will do with the exact amount of money they have received? Is that what that means? Because that would be the only way you could find out how much money it actually received, correct?
Ms. Martel: Okay, that's what's intended. Is there any way to make that clearer? The spending I can see, because I'm assuming they're going to set forward, "We're going to give this much to hospitals, this much to home care."
Ms. Mill: There is also the public accounts that require an itemization of the spending, so in addition to the requirement in the accountability agreement, there is also the requirement for the LHIN's spending to be enumerated in the public accounts.
Ms. Martel: I'd feel a whole lot better if it was articulated very clearly that the exact amount of money they received is outlined. The ministry tells me that's what the intent is, so I'll have to live with that.
"(1.1) Each accountability agreement entered into under subsection (1) shall be consistent with any agreements entered into between the minister and a person or organization mentioned in subclause 5(1)(h)(ii)."
Again, it is coming from CCN. It's consistent with earlier attempted amendments that failed and ensures that accountability agreements between the minister and LHINs are consistent with the agreements entered into between the minister and these province-wide organizations.
This follows from a previous amendment that would have made it clear that savings could not be deducted from a global amount of money provided to the LHINs in any given fiscal year. This amendment would have made it clear as well that the savings themselves would have to have been put back into patient care in that LHIN district.
"(3) If the minister and a local health integration network are unable to conclude an accountability agreement through negotiations, they shall follow the prescribed process for entering into an accountability agreement."
The arguments I'm going to put forward and the recommendation come from the Registered Nurses Association of Ontario. As you know, currently, if there's no successful conclusion of an accountability agreement, the minister has the power to impose. This would amend the bill, recommended by RNAO, for a dispute resolution process when there is no agreement. This would ensure that a LHIN's autonomy is not undermined by the provision of the minister to set the terms of the agreement solely. It's a vehicle I would support.
This was done because a previous amendment was moved that would have outlined very clearly the list of the requirements for the LHINs to be accountable, what would be on the website, what would be posted, the nature of the meetings, reports, documents, information etc. that would be required, but that wasn't accepted so this won't be either.
My apologies to the members. This probably should have come before the other one. The point was to make it very clear that each LHIN shall maintain a website and sets out those articles or items that have to be on the LHIN's website for access by the public. It is quite broad, including accountability agreements, service agreements that it's entering into with individual health care providers, and other details that are listed, so that the public clearly has an idea of what organizations the LHIN has a relationship to, what are the responsibilities of the parties, and other decisions that the LHIN wants to make with respect to integration, its meetings etc. So in the broadest possible way, these are some of the criteria -- there may be more -- that we could think of that should have to be posted for public consumption.
Ms. Wynne: We've brought forward amendment 122a. I think Ms. Martel just had that conversation with staff. So 122a does virtually all of this. It puts the proposed public notice requirements out in the legislation, so I won't be supporting 62.
Ms. Mill: The requirement for the accountability agreement is in 18(5), as I mentioned, and is then again referred to in the proposed motion on 122a. The requirement for publishing the service accountability agreement -- sorry, I'm just looking for that motion.
The proposed government motion number 140 requires the service accountability agreement that would be negotiated between the LHIN and the health service provider to be made public, as well as a requirement for the health service provider to make the service agreement available at each of its sites of operation. Then, again, government motion 122 would require that to be posted on the website.
The details regarding the integration decisions: The government is proposing to introduce motions regarding that. I'll just get those references for you. They are government motions 94 and 98, which deal with the integration decisions and a requirement for those to be made public. Then, again, motion 122a would require the posting on the website.
This is from the Association of Ontario Health Centres, and as we know, this would apply to certain health providers such as community health centres that are mandated to provide services across LHIN boundaries. Integration and funding decisions obviously must reflect the need to accommodate the transience of many of their clients. This is seen as being crucially important in a community such as the city of Toronto, because we did not adopt the amendment to make Toronto one big LHIN. So they're currently going to be serviced by five separate LHINs.
Ms. Wynne: I wasn't exactly clear about what the official opposition was trying to get at with this amendment, but my understanding is that in the objects, 5(g), the LHINs are required to develop strategies and co-operate with other local health integration networks. That cross-LHIN process is already in place, so I'm not sure what this would accomplish in addition to that.
"(1.1) The funding that a local health integration network provides to health service providers under subsection (1) shall include specialized funding for long-term care based on the unique needs of the relevant local population."
Obviously, it's from the Ontario Long Term Care Association. They believe LHINs should have the responsibility for granting funding for specialized programming that relates to their specific local population and that it should be up to each LHIN to determine the need and appropriate provider to deliver specialized programs that could include dialysis, developmental disabilities, psycho-geriatric convalescent care. This approach would encourage community partnerships among the different health service providers, which would aid the LHINs in addressing their mandate of achieving health integration.
Again, this is from the Ontario Long Term Care Association. This would require the LHIN to consult with health service providers to help determine the funding that is appropriate for specialized programs. Of course, the other amendment was lost. So I withdraw this.
"8. Consistency with the integrated health service plan, the provincial strategic plan, provincial funding policies, provincial programs and services and other provincial plans and standards, and the roles and responsibilities of the health service provider.
This is coming from Yee Hong, Sick Kids, OHA and Bloorview MacMillan. There is some concern that without these types of specific requirements taken into consideration, the needs of some of the service users outside of their catchment areas to access culturally appropriate services, for example, might be at risk. Also, Sick Kids believes that the funding model must recognize and address the increased financial burden that would be placed on facilities like Sick Kids which, as you know, treat the children who have the highest acuity. They believe there is a need for a streamlined method of funding to address the volume of children that they see.
This amendment enshrines the funding principles that have been arrived at over the last several years between the OHA, the joint policy and planning committee and the Ministry of Health and Long-Term Care. The emphasis is on multi-year accountability, sustainability, value for money and these principles which have been established. As I just said, it is believed -- and I would support it -- that they must be carried over to the new funding arrangement between the LHINs and the health service providers.
Ms. Wynne: Mrs. Witmer's got a lot more of the history than I do, but my understanding is that the funding formulae are still under development, that those principles aren't all in place. There have obviously been long discussions, but they're ongoing. To include this amendment would perhaps prejudice that process. So on all these issues, I won't be supporting the specificity around funding.
Mrs. Witmer: I appreciate what Ms. Wynne is saying, but you can well imagine that the stakeholders in Ontario must be somewhat fearful that all of the funding arrangements that are currently in place could be changed, and at the end of the day, they may receive less funding than they currently receive; there is not a lot of stability and security in the system. But anyway, I do acknowledge and accept that point.
Again, from the OHA and Bloorview MacMillan. This amendment and the one that immediately follows are two parts of the same amendment. The legislation currently allows the minister to assign his rights under all or part of an agreement. This could then extend to include agreements such as hospital on-call coverage and the alternate payment agreements, even though doctors are not considered providers under this bill.
Since these agreements are now centrally negotiated and the physician services will be centrally governed, these agreements, to which physicians are a party, must remain centrally administered. This amendment and the one that follows will ensure that that is the case.
"(3.1) Despite subsection (3), the minister shall not assign to a local health integration network an agreement for the provision of funding for services by a person described in subsection 2(3) that the minister has entered into under the authority of paragraph 4 of subsection 6(1) of the Ministry of Health and Long-Term Care Act or subsection 2(2) of the Health Insurance Act."
"(9) In the event of a conflict between a discretion as to funding of long-term-care facilities conferred under this act and the requirements of subsections (5) to (8), the requirements of subsections (5) and (6) prevail."
This is an amendment we've been asked to put forward by the Ontario Long Term Care Association. I'll hearken back to what I said before: Experience in other provinces has shown that when you devolve accountability as we are doing here, you do see variations in basic programs throughout the province. Unfortunately, sometimes some members of the public in certain LHINs then are not served as well as in other communities. For example, that report I referred to before of the provincial auditor in Alberta showed that funding for long-term care across the province of Alberta actually fluctuated by as much as -- get this -- $10,000 per head. That's a lot of money. A centralized funding framework such as proposed by this amendment would be crucial to mitigating any differences based on geography. It would provide stability as well for operators and their creditors and it would provide a framework for centralized funding based on beds and would require the LHINs to comply with the centralized funding formula.
Ms. Wynne: I have a couple of comments: As I've said before, the isolating of one sector I think is not appropriate for this legislation. The other issue is, as I've said before, that the funding formulas are being developed. There's another problem with this, as I read it: that this amendment would actually require the government to pay for capacity. It would require the government to pay for beds, whether they were being used or not -- pay for empty beds.
Mr. Maisey: That's right. Then there are some other programs that allow, in certain circumstances, for a home that meets certain conditions, where its capacity is less than 97%, an extra margin on top of its percentage capacity. I can't remember the name of the program.
That is the one section of the bill where patient mobility to access services is not permitted, so removing it from the act would make it clear that there is not a restriction on where patients can access their services, including either hospital services or home care services.
This has been requested by the Ontario Long Term Care Association because today some service providers have operations that will only be partially funded by the LHINs; for example municipalities, charitable organizations and private sector companies. As written, the legislation requires providers that receive any funding from the LHINs to submit to audits of their accounts. This amendment will ensure that only those portions of a provider's business that is funded by a LHIN are open to an audit. And they can't audit, obviously, the entire charitable organization, private sector company or the municipality.
"(2.1) No regulation made under this act shall prescribe a laboratory for which a licence is issued under section 9 of the Laboratory and Specimen Collection Centre Licensing Act as a prescribed person or entity for the purpose of subsection (2)."
This is a recommendation put forward by the Ontario Association of Medical Laboratories. If you take a look at the legislation as it's currently worded, it allows for a regulatory change that could require these laboratories to divulge to the LHINs plans, reports or any other information that the LHINs decide they need. It is inappropriate for the LHINs to be able to access confidential business information, especially when there are currently no safeguards whatsoever in place to require that the information they would obtain from these laboratories would be held in confidence. This amendment will prevent regulatory changes requiring the labs licensed under the Laboratory and Specimen Collection Centre Licensing Act from having to provide this confidential business information to the LHINs.
Mrs. Witmer: This is confidential business information. There are no safeguards in place currently. Once the LHIN has this information, there's no guarantee it's not going to be shared with other people.
"(2) In addition, each local health integration network and each health service provider shall, separately and in conjunction with each other, work with the persons and organizations mentioned in subclause 5(1)(h)(ii) to identify the opportunities described in subsection (1).
"(3) At least 30 days before identifying opportunities to integrate the services of the local health system under subsection (1), a local health integration network shall give notice in writing to all parties that could be affected by such an integration."
This is consistent with some earlier amendments that province-wide organizations be consulted when integration possibilities are being considered. It would require the potential parties to an integration order to be notified 30 days prior to any consideration process of the potential integration. It would allow for community engagement in order to achieve the integration. This advance notice would allow the health service providers who might be subject to a potential order to fully participate in the decision-making process and provide their input. It would ensure an open, transparent process and maximize the consultation.
"24.1 If a health service provider integrates its services with those of another person or entity and a local health integration network obtains information pertaining to the integration, the network shall not disclose the information to another local health integration network or another health service provider unless both the health service provider doing the integration and the other person or entity consent."
Currently, a large number of laboratories in the province have a relationship with hospitals and they provide a range of services through agreements and contracts. These services provided range from management of labs to providing reference testing services. These agreements and contracts contain proprietary financial information. This amendment would allow the LHIN to fully explore integration opportunities, while at the same time protecting proprietary information contained in agreements between the lab and the health service provider.
Ms. Wynne: The concern of this legislation is that the dissemination of best practices happen smoothly, and this amendment could provide a barrier to that, truncating the flow of information, so I won't be supporting it.
Ms. Wynne: I move that clauses 25(1)(b) and 25(2)(a) of the bill be amended by adding "where at least one of the persons or entities is a health service provider" after "the integration of persons or entities" wherever that expression appears.
The intention was that LHINs could only write integration decisions where at least one party was a health service provider. The previous language was not clear on this, so this is a clarification of that.
"(2.1) Despite the Personal Health Information Protection Act, 2004, an integration decision may require one or more health service providers to transfer or receive records of personal health information as defined in section 4 of that act.
"(2.2) If a local health integration network issues a decision requiring a health service provider to transfer records of personal health information as defined in section 4 of the Personal Health Information Protection Act, 2004, the health service provider shall take reasonable steps to ensure that the transfer of the records is undertaken in a secure manner."
This has been requested by the Ontario Hospital Association. As you know, some of the integration decisions that are going to take place are going to require the transfer of personal information, and that may require the consent of individuals before that information is transferred. This would arise when integration decisions do not result in the creation of a successor within the meaning of section 42 of PHIPA.
This is really a practical concern. Requiring providers to obtain individual patient consent presents potentially significant barriers to smooth and efficient integrations. This amendment basically would allow the transfer of personal information to take place when required by an integration decision, despite PHIPA, but it also requires health service providers to ensure the transfer happens in a secure manner. So it's intended to facilitate that, but at the same time provide some protection.
Mr. Maisey: This was an issue that we thought about and considered that section 42 of the Personal Health Information Protection Act would do the trick, and that there would be a successorship when there is a transfer of a service, so records would then be able to be moved under that section, including giving notice to patients or other people whose records are being moved.
A number of people came before the committee who expressed concerns that part of the result of this bill would be that a number of services that were offered in hospitals would no longer be considered core services and would go out into the community, in some cases without any corresponding funding going out to ensure that people could still access them. You have the spectre that this has already happened, for example, at St. Mike's. They had a psychology clinic in the hospital that was covered, so a very vulnerable population serviced by St. Mike's. Many people who had mental health problems, for example, could actually access that service and not have to pay. When St. Mike's moved that service out of the hospital and into the community, those costs then had to be borne by clients who still wanted to access the service, because psychology services also are not paid under OHIP, essentially. So that caused a very significant problem for a population that already has trouble accessing services.
The problem is, that is permitted by law currently. So there was nothing that could be done. Those folks were charged a fee, and those who couldn't afford to pay didn't get the service otherwise. A lot of people didn't receive the service any more. The concern that was expressed by a number of groups is that it's all well and good that that might be covered by law, but when that service is moved out of the hospital, it shifts the financial burden on to many patients who may well not be in a position to pay for those services themselves, because they're not covered by OHIP and they're not covered any other way.
The purpose of the amendment is to ensure that that's not the kind of thing that's going to happen under this legislation, that more and more hospital services are essentially offloaded into the community, where people are going to be forced to pay for them out of their own pockets.
"(3.1) No integration decision shall alter the terms and conditions of a collective agreement binding on an employer who is party to such a decision or of the terms and conditions of employment of the employees of that employer without the agreement of,
"(b) in the case of employees represented by a trade union, without the agreement of the bargaining agent that has bargaining rights in respect of a bargaining unit that is subject to the decision, except as provided by the Public Sector Labour Relations Transition Act, 1997.
"(3.2) No integration decision shall be issued before the parties to the decision have met with every bargaining agent that has bargaining rights in respect of a bargaining unit that may be affected by the decision and the parties have, in good faith, made every reasonable effort, including, but not limited to mediation, to agree to a human resources plan.
"(3.4) No integration decision or funding allocation shall be issued before the local health integration network has given public notice of the proposed decision in accordance with section 18.1 and has provided potentially affected persons and entities to make representations."
This was given to us as an amendment by both the Ontario Nurses' Association and OPSEU. I think it's clear that the focus is to make sure that (a) the integration that's going to go on under this bill is not going to result in a transfer of services from not-for-profit entities to for-profit entities. That would just ensure that health care dollars that should go to patient care instead end up going to profits of some of those for-profit companies. It also makes it very clear what the rights are of affected employees and what efforts have to be made to deal with those employees as integration decisions get carried out. Then there is the notice provision as well, which would allow for the bargaining agent, if there is one, with respect to those employees to work with the employer to agree to a human resources plan so that there's not significant disruption with respect to the services that those employees are trying to provide to the public.
Ms. Wynne: The concern with this amendment is that it could protract integration processes. Also, we're bringing forth amendment 85, and the PCs have brought forth amendment 84, which actually lays out the need for a human resources plan. So I won't be accepting this amendment.
Ms. Martel: Ms. Wynne, references on both pages 84 and 85 do speak to a human resources plan, which needs to be spoken to in the context of what's happening here. We heard that again and again. Neither of them, however, speaks to the very serious concern that was raised by a number of presenters -- not just potentially affected employees, but a number of the seniors' organizations and health coalition representatives -- that integration decisions should not result in changes to benefit for-profit health services providers.
The last thing we want to see, if this government truly is committed to Bill 8 and to the Canada Health Act, is an increased proliferation of health care providers. Neither of the two amendments that were referenced by Ms. Wynne speaks to ensuring that integration decisions are not going to result in a transfer of health care services from the not-for-profit to the for-profit sector. I think that should be a serious consideration by this government, one that they would be amenable to accepting.
Ms. Martel: Just very briefly, the preamble states that the principles -- this would provide a clear detail in the bill that would essentially say that that kind of integration decision is prohibited. The preamble as a statement of principle doesn't put that principle into effect. This amendment would put that principle into effect in this section, to ensure that integration decisions will not adversely affect not-for-profit health care delivery or not-for-profit agencies in the province.
I believe we were going to be here until 7; it's just after 7. We will end this session until tomorrow at 10 a.m. Thank you, goodnight, and a happy Valentine's Day to all of you. Thank you to the minister, or his staff or whoever, for sending us a present here.