The Ontario Council of Hospital Unions (OCHU) is the hospital bargaining council for CUPE in Ontario. OCHU bargains a central template agreement with the Ontario Hospital Association.
OCHU represents approximately 25,000 hospital employees in service and office hospital (and some long term care) bargaining units from one end of the province to the other, from Windsor to Hawkesbury, Sudbury, Kenora and Fort Frances, with members in most communities in between. OCHU represents the workers who (usually) are the paid the least in hospitals: dietary workers, registered practical nurses, cleaners, operating engineers, secretaries, ward clerks, porters, carpenters, cooks, personal support workers, lab assistants, etc.
Not surprisingly, most OCHU members are women. We note that while spending on other areas (e.g. pharmaceutical drugs and supplies) has risen very significantly, spending on Canadian hospital support services has shrunk as a percentage of total hospital spending. Indeed in recent years it has shrunk in absolute terms. OCHU takes great pride in our long-standing campaigns in favour of universal, accessible, comprehensive, publicly funded and publicly delivered health care. We are very concerned about the impact of Bill 36 on these principles and so have taken some pains to date to apprise the community. We are concerned that we may have to step up our activities.If passed, Bill 36 will give government and the LHINs new and troubling powers to restructure public health care and social services. Centralization
Centralization, Consolidation, and Privatization
Once again, the Ontario government wants to “transform” health care and certain social services – this time by creating Local Health Integration Networks (LHINs). Fourteen LHINs have been established in the past year to plan, integrate, and fund hospitals, nursing homes, homes for the aged, home care, addiction, child treatment, community support, and mental health services. Ambulance and public health services have been (as Health and Long Term Care Minister George Smitherman says) “initially” excluded, along with privatized labs and clinics. The government has allowed doctors to escape the LHINs.
The LHINs are local in name only. The Bill would grant little real power to local communities and providers to make decisions. Rather it transfers control over local community based providers to the Minister and Cabinet, and to their agents (LHINs), thereby centralizing, rather than localizing, control over health care (and certain social services) in Ontario. The Bill grants unprecedented authority to the Minister of Health and Cabinet to effectively control most public health care service providers and to completely restructure public health care delivery, including the power to turn delivery over to for-profit corporations.
The government describes the legislation as a “made in Ontario” solution that would give power to the local level. It distinguishes this reform from “regionalization” in other provinces, as LHINs will not directly deliver services.
In fact, the government’s reform takes the worst aspects of health care regionalization in other provinces and combines it with the worst aspects of health care restructuring in England. It would create a new layer of bureaucracy that would  be unaccountable to local communities,  reduce provincial government accountability for the largest part of its budget, and  create a “purchaser-provider split” that will undermine health care and social services.
What follows is an outline of these problems and their likely consequences. We will also suggest some very different reforms that could actually improve health care and social services in Ontario.
 Community Control and Provincial Government Accountability
The LHINs cover vast and very diverse areas. The LHIN boundaries have been formed based on hospital referral patterns, overriding municipal, provincial, and social boundaries. The proposed LHINs are not “local”, they are not based on communities, and they do not represent communities of interest. As a result, they lack political coherence. So it will be very difficult for the people living within a LHIN to have a significant voice over the direction of that LHIN, even if the LHIN board wishes to listen.
The autonomy of the LHINs from the government is very modest. With this Bill, Cabinet may create, amalgamate, or dissolve a LHIN. A LHIN is defined as an “agent of the Crown” and acts on behalf of the government. LHINs are governed by a board of directors appointed by Cabinet and paid at a level determined by Cabinet. The Government determines who will be the Chair and Vice-chair of those boards. Each member continues on the Board at the “pleasure” of Cabinet and may be removed at any time without cause.
The government will control LHIN funding, and each LHIN will be required to sign an accountability agreement with the government. Indeed, the government may unilaterally impose this even if the LHIN does not agree to the “agreement”. In addition, the LHINs integration plans must fit the provincial strategic plan.
So LHIN boards will be responsible to the provincial government rather than local communities. This is in contrast with a long history of health care and social service organizations in Ontario, which, as a rule, are not appointed by the provincial government. For example, hospitals boards are not appointed by the provincial government. They have doggedly pointed out the need for better care in their communities, with significant success. The previous government attempted to cut hundreds of millions of dollars from local hospitals, but when local hospitals helped to point out to their communities the problems this created, the government reconsidered. The cuts were reversed and the hospitals were allowed to continue to provide decent (if still under-resourced) care.
Recently, however, the government has found a way to blunt criticism of under funding (and privatization). The key was to replace community boards with government controlled boards. This unfortunately is the model for LHINs. The results of this experiment in Community Care Access Centres (CCACs) suggest that it is a very poor model for LHINs to follow.
CCACs were taken over by the provincial government in 2001. CCACs immediately ceased pointing out to the public their need for adequate funding. The result? Their funding was flat lined for years and home care services were cut back dramatically. Tens of thousands of frail elderly and disabled lost their home support services. In total, the effect was a reduction of 115,000 patients served from April 1/01 - April 1/03 and a cut of 6 million hours in services - a 30% drop. As one government report calmly noted:
As prices went up and funding levels remained constant, CCACs had to discontinue certain services in order to maintain balanced budgets. These changes occurred independently without provincial co-ordination and clear communication. The emphasis shifted from homemaking services to the provision of personal support.
So in Kingston, as in other parts of the province, there were increasing restrictions on supportive care that helps people stay in their homes. People could not get a bath or other supportive care like help around the house unless there was also a nursing requirement. The result was that more people ended up in the hospital or long term care facilities as they were unable to take care of themselves at home. People just could not stay in their houses. The number of visits for acutely ill people was also standardized in Kingston – so someone coming out of a hospital with a heart bypass would get the same number of visits whatever their circumstances – e.g. a young man with support in the home and an elderly widow with no family nearby. People could of course fight for more services but the objective appeared to be to download as much as possible on families, with women bearing the brunt.
Government controlled regional agencies are a poor model for health care and social service reform. Yet, this is what we are facing.
Flak Catchers: LHINs will insulate government from decisions to cutback or privatize services by creating another level of bureaucracy that will catch much of the “flak”. The government will control LHINs but the LHINs will actually implement decisions. They will be the first targets for popular discontent, even if their actual autonomy from government is more imaginary than real.
Conflict within the LHINs? The large, socially diverse areas covered by the LHINs, also suggest that there will be significant conflict over resource allocation. What services will the LHIN provide in each area of the LHIN? Unlike government, LHINs will not be able to increase revenue. Smaller communities may be the first to see their services “integrated” into other communities.
Strengthen Community Control: The LHIN structure puts up significant barriers to local community control of health care. Conflicts between communities within a single LHIN are likely with small communities particularly threatened. Likely, the provincial government will respond to complaints by stating, “It was not our decision – it was a decision of the LHIN.” Yet, the LHIN will largely be unaccountable to local communities. These serious problems suggest another direction must be investigated:
- We need to provide for the democratic election of LHIN directors by all residents in the LHIN geographic area, with selection of the Chair and Vice-Chair by the elected directors. Local Members of the Provincial Parliament should be ex-officio directors of the LHINs.
- There should be a requirement in the Bill for extensive public consultation on the existing geographic boundaries of the LHINs. LHIN boundaries should reflect real communities of health care interest so local communities can have a real impact on LHIN decisions. We also need a requirement for real public consultation when Government proposes to amalgamate, dissolve or divide a LHIN.
- We need a Ministerial obligation to meaningfully and fully consult the community prior to imposing an accountability agreement on a LHIN.
- We need a requirement that each LHIN must establish a health sector employee advisory committee, made up of union representatives and representatives of non-unionized employees.
- We need to eliminate Cabinet’s authority to enact regulations closing LHIN meetings to the public.
We need to ensure the right to seek reconsideration, and for full judicial review, by any affected person, including trade unions, of any LHIN, Ministerial or Cabinet decision or regulation.
 Access to Health Care Services
Sweeping Government Powers to Restructure
Bill 36 gives LHINs and the government a wide range of tools to restructure public health care organizations. First of all, the LHINs have their funding powers to “facilitate” consolidation (s. 25). They also have accountability agreements with health service providers. While these powers may appear sufficient, much more powerful tools have been given to the LHINs, the Minister of Health and cabinet to force consolidation.
- LHINs are given the power to issue compulsory “integration” decisions requiring health care providers to cease providing a service, or to transfer a service [s. 26(1)].
- The Bill gives the Minister even more powers to order integrations directly. Specifically, the Minister may order not for-profit health service provider to cease operating, amalgamate, or transfer all of its operations [s. 28]. For-profit providers are exempted from this threat.
- The Bill allows cabinet to order any public hospital to cease performing any non-clinical service and to transfer it to another organization [s. 33(1)]. This means that the Government can centrally dictate how all non-clinical services are to be provided by hospitals, including through privatization. The Bill gives cabinet the authority to contract out these services despite the wishes of the hospital. There is no definition in the Act of “non-clinical service” and so this definition may be a matter of considerable controversy.
The government refers to this restructuring as “integration”, stating that the goal is the creation of “seamless care” and a true health care “system”. But this is misleading: the LHINs restructuring will not unite hospitals, homes, doctors, laboratories, home care providers, and clinics as in other provinces. Worse, the LHINs purchaser-provider model (discussed in section 3 below) will increase competition between providers. And plans to spin work off to for-profit corporations, private clinics, and regionally based support service providers will mean more fragmentation and less integration, as set out below.
A key goal of this reform is to constrain costs by “integrating” services. But this also raises questions about cutting services in local communities. At first, the government talked only of integrating support services. But cutting back support services is dangerous (hospital acquired infections already kill thousands in Canada every year) and inefficient (it often requires more highly paid staff to take over the functions formerly done by support staff).
The government plan is to regionalize hospital support services. With government support (from OntarioBuys), dozens of hospitals across the north are planning to consolidate supply chain and office services by turning work over to a new employer, Northern Ontario Hospital Business Services (NOHBOS). Likewise, with government support, 14 hospitals in the Greater Toronto Area plan to regionalize supply chain and office services by turning work over to another new organization, Hospital Business Services (HBS). This organization would take approximately 1,000 employees out of the hospitals, turn over a significant portion of the work to for-profit corporations, and sever roughly 20-25% of employees. This is a major change that may have far ranging consequences for workers and local communities. And more such plans are in the works…
Like so much of restructuring, these moves will have a major negative impact on hospital support workers. But, they certainly will not create “seamless care” for the patients. Instead, they will create more employers and bring in more for-profit corporations into health care. In many respects, it will create more fragmentation.
Clinical Services Threatened: The hospitals insisted that an exclusive focus on support services would not satisfy the cost savings demanded by the government – the savings would also require clinical cuts. By April 2005, the government admitted as much, with the Health Minister publicly calling for the centralization of hospital surgeries: “We don’t need to do hip and knee surgery in 57 different hospitals”. Instead, he suggested that about 20 – i.e. a 60% cut – might be appropriate. The Minister went on to indicate that hospital specialization is the order of the day:
“Each hospital in Ontario will be given an opportunity to celebrate a very special mission … but not necessarily operating with as broad a range of services as they’re tending to right now.”
This squarely raises the prospect of even more travel (to multiple sites) for health care services.
The government has also begun to move surgeries right out of hospitals and place them in clinics. The first instance was the recent creation of the Kensington Eye Clinic. This clinic (in the recently closed Doctor’s Hospital in Toronto) is supposed to remove 1,700 procedures from hospitals and do an additional 5,000 cataract surgeries. This, the Minister says, is only the beginning.
But the creation of new surgical clinics only fragments health care, creating more employers and more destinations for seniors to run around to as they tend to their health care needs. It also raises the possibility of the establishment of for-profit surgical clinics. Indeed, when the Health Minister announced his interest in surgical clinics in the spring of 2005, the chosen sponsor of his speech (University of Toronto academic John Crispo) proposed private sector clinics providing two-tier care as soon as the Minister sat down.
A better solution would be to create surgical clinics in the facilities and organizations in which we are already invested. Hospitals have the infrastructure needed to support these surgical clinics. There is no need to duplicate their human resource, stores, payroll, purchasing, cleaning, food, laboratory, and other support services. Hospitals also have the resources to deal with emergencies that may occur during operations. And this would actually help advance the “seamless care” that this reform is supposed to create!
Secretive Budget Cuts
Even before the LHINs have been given funding responsibilities, some Ontario hospitals have developed budgets for the coming year that will see cuts to direct health care services. As Provincial Affairs Columnist, Ian Urquhart, notes:
Ordinarily, this would be the subject of heated public debate. But most of the proposed cutbacks have remained confidential to date and, accordingly, there has been little public backlash.
The Peterborough Examiner took on the idea of keeping the discussion of the proposed cuts at the local hospital secret. Their argument is worth noting:
Local hospital officials miss the point when they say that keeping budget negotiations secret until all the details have been approved is less stressful for everyone involved. …It is hard to believe that several weeks of protests from doctors, patients and their families, municipal politicians and the community at large had no effect on the outcome. …People can deal with news, good or bad, but they need all the information. In fact, they have a right to deal with it, and to decide for themselves whether their voices have an impact.
The LHINs threat of reduced community control and provincial government accountability (discussed above) suggests that the trend towards secretive cuts could become worse if the LHINs are given funding responsibilities. The question of transferring funding to the LHINs raises serious concerns.
We note that when local communities have found out about hospital cut backs in recent months, there have been vigorous, spontaneous fight backs.
- In tiny Picton, a capacity crowd of at least 500 turned out at the local community centre in September when three critical care beds, laboratory services and day surgery at the Picton hospital site were threatened.
- In Ajax, 1,100 rallied when the obstetrics/paediatric program came under threat in December.
- In Sarnia, over a thousand rallied at City Hall in August despite crippling heat, and 21,000 people signed a local petition when the government ordered the hospital to cut its deficit, threatening palliative care.
Notably, these spontaneous campaigns often achieved significant success. Local services are under threat – we cannot let local communities be shut out!
Different LHINs, Different Levels of Funding: Different Levels of Care?
LHINs are to be given powers to fund and manage health care and social services. This raises the question of whether service levels will vary by LHIN. Home care in Ontario operates through government controlled regional bodies that purchase home care services (i.e. CCACs). So it is notable that home care services vary by region. Indeed, even the service cuts that followed the government take over of CCACs in 2001, “occurred independently and without provincial coordination” according to a government study.
Currently, we have no sense from the government of how far it will allow regional variation to proceed, yet the consequences could be quite significant.
Will Cost Savings Even Be Achieved?
Consolidation of services doesn’t necessarily mean cost savings. The most recent government experiments with consolidation have been associated with increased costs. The merger and closure of hospitals directed by the Health Services Restructuring Commission (HSRC) in the 1990s did not lead to reduced spending on hospitals and health care – indeed, there has been a significant increase in spending. And many HSRC directed hospital-restructuring projects left a shambles for exhausted and demoralized hospital staff to clean up.
The second instance of government-led centralization of services in the 1990s was the centralization of jail services. Two large, centralized jails were built along with a new centralized facility to cook and chill jail meals. The result did not impress the provincial auditor general. Existing institutions actually produced food more cheaply. And the new cook-chill facility was only able to supply six institutions instead of the promised ten. Despite a decline in the average inmate count, operating costs for institutional services increased by 19% over four years.
The LHIN reform does not directly deal with the undisputed real health care cost drivers: soaring costs for drugs and equipment supplied by trans-national corporations. Instead, health care workers and patients will bear the brunt.
Protect Local Services and Access to Care: “Integration” will remove jobs and services from local communities hampering access. Support services are likely the first target, but direct clinical care is also under attack. Reductions in community control and provincial government accountability will make it easier for government to implement these threats. We need fundamental change:
- Provide in the Bill that Cabinet, the Minister and LHINs may only exercise their powers in the public interest, with public interest defined to include preservation of the public, not-for-profit character of our health care funding and delivery system.
- Provide in the Bill that LHINs, the Minister and the Cabinet cannot order or direct integration, nor approve/disapprove integration. The power the LHINs have to withhold funding is power enough to encourage consolidations. The LHIN, Minister and Cabinet should not have the right to transform the health care system unilaterally, otherwise there is no reality to the claim that we are enhancing local decision-making and no point in retaining provider governance structures.
- Provide in the Bill that the LHIN, Ministerial or Cabinet power to withhold funding to force integration only be exercised where necessary in the public interest and where integrated services remain publicly delivered on a not for-profit basis.
- Provide in the Bill that transportation subsidies will be paid by LHINs if the required service is no longer provided in a given community. No purpose is served if “integration” creates new costs for residents.
- Provide in the Bill that nothing in the legislation authorizes Cabinet, the Minister or LHINs to override the terms and conditions of employment contained in freely negotiated or freely arbitrated collective agreements.
- LHINs should be required by the Bill to do an annual survey of unmet needs and to report unmet needs in annual reports to their communities.
 A New Form of Health Care Privatization
There are no provisions in the Bill which ensure, require or even encourage LHINs, the Minister or Cabinet to preserve the public, not-for-profit character of our health care system. Indeed, these bodies would now be armed with the legal authority to privatize large parts of our publicly delivered health care system. Moreover, LHINs will create a split between the purchasers of health care and social services and the providers. The LHINs will purchase services and hospitals, homes, community agencies, and for-profit corporations will provide them.
Even before the establishment of LHINs, we have seen a move towards the purchaser-provider system in Ontario hospitals and health care.
Cancer Care Ontario has ceased to be a provider of cancer care services and instead purchases services using a price based system. Likewise the new “wait times” strategy is based on the establishment by the Ontario government of prices for the various priorities. These services are then purchased though contracts with various providers. The hospitals have indicated that pricing will expand significantly. This move away from global budgeting will decrease the autonomy of local hospitals to meet local needs.
The purchaser-provider split has been established for nine years in home health care. Community care access centres (CCACs) purchase homecare services via contracts established though a system of competitive bidding. The results of this system have been extremely negative. The most reliable figures show that the percentage of homecare nursing market share provided by for-profit corporations increased from 18% in 1995 (two years prior to the introduction of competitive bidding) to 48% in 2001.
As contracts come up for renewal, homecare providers regularly lose contracts, and workers who have no successor rights, are laid off. In Cornwall, homecare staff have lost their jobs at least three times since competitive bidding was introduced. A recent snapshot study identified over 1,000 home care workers in Ontario who were laid off due to contract loses over an eight-month period.
Faced with this uncertainty, many of the workers naturally decide to work in other, more secure sectors, even if they love home care. A recent report on home care to the Ministry of Health and LTC found that fully 57% of the home care workers surveyed had changed jobs in the past 12 months. No industry, let alone a vital industry like health care, can sustain this sort of turnover and provide excellent service. The report also noted that 40% of home care workers surveyed indicated that they felt not too secure or not at all secure in their jobs and that the average wage for Personal Support Workers (a major home care occupation) is approximately $12 per hour. That is about $5 an hour less than what they would earn in a hospital.
Despite all these problems, the price to the province for home care services actually went up after competitive bidding was introduced. The effect of price increases on the amount of home care services provided was a sharp reduction in the services provided. Here is what even a government review notes:
As prices went up and funding levels remained constant, CCACs had to discontinue certain services in order to maintain balanced budgets. These changes occurred independently without provincial co-ordination and clear communication. The emphasis shifted from homemaking services to the provision of personal support. Clients and service providers told the CCAC Procurement Review that these changes were particularly difficult because it was unclear which services CCACs provide.
The problems with competitive bidding became so severe that the government has suspended the bidding process some time now. Despite these problems, Ontario government officials are now talking of extending the purchaser-provider split to other areas of health care and social services through the LHINs.
The Experience with Competitive Bidding in Social Services
Competitive bidding is also doing damage in social services with its introduction by Human Resources and Skills Development Canada. The new bidding process has, in the first round of proposals, disrupted over a third of the long-standing arrangements with community organizations. Three organizations are losing so much of their funding that they will have to close their doors. Four contracts have been awarded to the for-profit sector. Clients have no idea where they will be served, if at all, while the programs and linkages created over decades of work are being lost. Laid off social service workers are being forced to re-apply for their same jobs – at a lower rate of pay and benefits.
Over the last two decades, Britain has introduced the purchaser – provider split in health care, leading to a massive expansion of privatization. This change is now apparently influencing the Ontario government. With the introduction of the purchaser-provider split serious problems arose in Britain:
- Openings for privatization. With the split, every new contract has the potential to divert resources to the for-profit sector. For every £1 spent on National Health Service (NHS) staff in 1995, 71 pence was spent on procurement of goods and services from the private sector; by 2003, the figure was £1.15 for every £1 on staff.
- Fragmentation. While the Ontario government has sold LHINs as a way to integrate services, the purchaser-provider split has led to fragmentation in Britain. Funding comes by winning contracts. For its own survival, each hospital must now assess each cost as if that hospital stood completely alone in the health care system. But cost savings for a hospital can lead to cost increases for other health care providers.
- The establishment of private clinics and the expansion of private hospitals. Private diagnostic and surgical clinics have taken over work previously done in hospitals, despite costing more. The goal is now to have up to 640,000 surgeries carried out by private clinics each year. More work is also being done in private hospitals: services purchased by the public authorities from private hospitals will increase from £200m in the early 1990s to £2 billion pounds in 2007 – a 10-fold increase! Yet, a recent poll showed 89% against private provision of public health care.
- Service Shifting: For providers, services that are ‘profitable’ become the priority at the expense of other services. Even at this early stage of the introduction of the purchaser-provider split in Ontario, we are seeing signs of this: orthopaedic surgeons have already complained that the new Ontario wait time priorities [which are already purchased through a price-based system] are squeezing out other surgeries.
- Specialization: Hospitals that cannot provide a service for the set price either have to subsidize it from other parts of their budget or give up providing that service. This is quite unsatisfactory where alternate hospitals are at some distance.
In Ontario, where distances are particularly large, this could add in a lot of travel. But even where distances are measured in several kilometers rather than several hundred, specialization creates special problems. Instead of being able to deal with all of their problems at one centre, health care services are spread out over many health care providers – creating a real problem for those with multiple health issues, especially for the elderly, the poor and their families.
All of this change in Britain has only led to serious problems for British health care: despite more than doubling funding since 1997, the service is running into a funding crisis with debts totaling at least £750m, bed closures, operating theatres closures, service cuts, and estimates of 8,000 or more layoffs.
The changes that came to Britain may soon come to Ontario via the LHINs purchaser-provider split: repeated opportunities for privatization with each new tender for services, competition between services providers, increased fragmentation, increased private clinics and surgeries, and, with hospital specialization, more travel and the end of one-stop hospitals.
Stop Privatizing Health and Social Services: Build Cooperation
Privatization and decreased cooperation between providers are major threats of this reform. Instead of integration, privatization will bring “disintegration” with the various providers in competition to win contracts. Specialization will increase inconvenience and travel for patients. The institution of the purchaser-provider split and the expansion of privatization in health care and social services should not be part of health care reform. Again, we need to re-think this reform:
- · We need a requirement that prior to developing a provincial strategic plan [s.14], the Minister shall convene a province-wide consultation on the appropriate funding formulae for the LHINs and the appropriate funding formulae for each of the health service provider sub-sectors.
- · Competitive bidding models should be specifically excluded in the legislation, based on the disastrous results they have already brought to Ontario health care.
 Impact on Bargaining Units
The change in health care delivery contemplated by these reforms opens up possibilities for enormous changes in bargaining units, collective agreements, and collective bargaining. The Bill would extend the coverage of the Public Sector Labour Relations Transition Act, 1997 (PSLRTA) to many of the potential changes in employment that could result.
Health care and social service workers have been through many rounds of restructuring already. And we were always assured the various changes were for the best. But too much of this restructuring, simply consumed enormous energy and resources, exhausting health care and social service workers. Yet, we face change on an even broader scale now.
We are not convinced that the government fully recognizes the can of worms it is opening. As the workers faced with this change, we deserve, at a minimum, a fair process that will provide reasonable employment security and protect working conditions, collective agreements, and bargaining unit rights.
CUPE is closely examining the impact that Bill 36 and its use (in some cases) of the PSLRTA to deal with the labour relation issues raised. But, we can note that we are concerned that PSLRTA may not be applicable in cases where the entity receiving the work is not a health service provider and where the primary function of that entity is not the provision of services within the health sector. This may allow LHINs or government to transfer work without providing health care workers the right to a union representation vote.
Further, hospital bargaining has been based upon the use of the Hospital Labour Disputes Arbitration Act (HLDAA) for the settlement of contract disputes. Changes to this arrangement would put hospital labour relations in some jeopardy. HLDAA should continue to apply despite any and all of the restructuring contemplated by this Bill. Finally we would also like to make crystal clear that our collective agreements cannot be overridden by this Bill.
Protect Bargaining Unit and Employment Security Rights
- Provide in the Bill that PSLRTA applies regardless of whether a person or entity is a health service provider, and regardless of whether the primary function of the person or entity is to provide services in the health sector.
- Employees should continue to be governed by their existing conditions and represented by their existing union in the event of a transfer.
- Employees should continue to be governed by their existing collective agreement and conditions of employment and these should continue to be determined through central bargaining and the Hospital Labour Disputes Arbitration Act (HLDAA).
- Remove from the Bill, the proposed Cabinet authority to exempt application of PSLRTA.
- Provide that nothing in Bill 36 or the application of the PSLRTA can have the effect of overriding collective agreement provisions.
For all these concerns, we believe this Bill and the government’s attempt to restructure health care needs to be rethought. We have made some suggestions for how health care reform could unfold. But we urge the government to take a considered and consultative approach. We had no sense before the last election that the government would embark on the path it has taken. We believe that a better approach would be to consult with local communities, health care workers, and the public about how health care should be reformed. That would be a much more satisfactory and much more democratic process.
We would like to thank the Committee for listening to our concerns and suggestions.
DA:dm cope491 H:Nat’l RepsAllan, DougOCHU Brief - Bill 36 - Jan 30-06.doc
 National Health Expenditure Trends, 1975-2002, Canadian Institute for Health Information.
 “Doctors do not come under the umbrella of this legislation. Physician services are a large provincial program that requires provincial standards and management. It is also more efficient and practical to continue to run this program centrally” Source: “Notes for Remarks by the Honourable George Smitherman, Minister of Health and Long Term Care,” Empire Club of Canada, November 24, 2005.
 The legislation also reforms the Community Care Access Centres (CCACs) in a move that would see the consolidation and reduction in the number of CCACs.
 The experience in other provinces is that government soon changes the regional health authority boundaries, usually making them larger. Notably, this is precisely what is happening to CCAC boundaries.
 Bill 36 would require LHINs to “engage the community” and establish a health professionals advisory council (s.16). But details of these requirements are left out. At best, these are modest requirements.
 Elinor Caplan, Realizing the Potential o f Home Care, 2005, p. 59.
 We understand that CCACs are now to be given some more local control, but this is all the more reason that the government control model should not now be applied to LHINs.
 Indeed before the legislation was introduced, the Minister had put considerable emphasis on the LHINs funding power: In a major April 2005 speech where he raised the idea of hospital specialization and a new surgical role for clinics he noted: “Local health integration networks will have the power to do funding and from that power is going to be the capacity to get that kind of stuff done.” Source: Rob Ferguson, “Plans under way to open cataract surgery clinic,” The Toronto Star, Fri 08 Apr 2005 Page: A13.
 Zoutman et al, “The state of infection surveillance and control at Canadian acute care hospitals,” American Journal of Infection Control, 2003:31, 266-275.
 The severance numbers are extracted from Hospital Business Services Prospectus, December 2004, Appendix F.
 See, for example, OHA, “Ontario’s Hospitals Forced To Make Critical Choices About Services They Can No Longer Provide,” and “ Ontario hospital funding backgrounder,” both released September 3, 2004, at http://oha.com, communications / media releases / archives.
 Rob Ferguson, “Plans under way to open cataract surgery clinic,” The Toronto Star, Fri 08 Apr 2005 Page: A13.
 Keith Leslie, “Hospitals will be forced to specialize: Plan called boon to patients, bottom line,” The Kingston Whig-Standard, Fri 08 Apr 2005, Page: 13
 Keith Leslie, “Hospitals will be forced to specialize: Plan called boon to patients, bottom line,” The Kingston Whig-Standard, Fri 08 Apr 2005, Page: 13
 Michael M. Rachlis, Public Solutions to Health Care Wait Lists, Canadian Centre for Policy Alternatives, December 2005.
 See Ian Urquhart, “Cuts feared as hospitals try to balance budgets,” The Toronto Star, Wed 26 Oct 2005. Also note the controversy over keeping budget cuts secret in Peterborough: Trevor Wilhelm, “Hospital’s ER doctors fear cuts,” The Peterborough Examiner, Friday, September 30, 2005,Page: A1 / FRONT; the editorial, “What’s up?: Public must hear details of planned cuts before they are final,” The Peterborough Examiner, Friday, September 30, 2005, Page: A4, and “Hospital Budget Shrouded in secrecy; unclear if BGH will run deficit for 05-06,” Brockville Recorder and Times, Wednesday, September 14, 2005, Page: A4, Byline: BY Nick Gardiner.
 “What’s up? Public must hear details of planned cuts before they are final,” The Peterborough Examiner, Friday, September 30, 2005, Page: A4
 ‘Picton hospital not safe yet: Doctors, politicians fear service cuts despite budget reprieve,” The Kingston Whig-Standard, Monday, September 26, 2005 Page: 6, Byline Bruce Bell.
 Local health care petition headed for Toronto, The Observer (Sarnia), Wednesday, October 12, 2005; “Planned cuts protested,” The Observer (Sarnia) Thursday, September 15, 2005 Page: A1, Byline: Jack Poirie; “City rallies against cutbacks: Health minister expected in Sarnia today,” The Observer (Sarnia), Thursday, August 11, 2005,Page: A1 / FRONT, Byline: Neil Bowen
 Elinor Caplan, Realizing the Potential of Home Care, 2005, p. 59.
 See the Change Foundations Financial Review Of Ontario Hospitals Trends in Financial Results 1997 to 2003, pages 7-8 for the huge cost increases for these items: “Over the past six years, these expenses have risen from 18% of total operating expenses to 24%.” Ontario government expenditures on pharmaceutical drug programs have also seen staggering increases. The government must deal with the large cost increases originating from for-profit health care.
 For a detailed discussion of this and other issues regarding home care and competitive bidding, see the Ontario Health Coalition’s March 31, 2005 report Market Competition in Ontario’s Homecare System: Lessons and Consequences at http://www.web.net/ohc/Homecare.htm.
 OHC, Market Competition in Ontario’s Homecare System, 2005.
 Elinor Caplan, Realizing the Potential of Home Care, 2005, p. 23.
 Ibid, p. 25 and p. 28.
 Ibid, p. 35.
 Ibid, p. 59.
 Note Ian Urquhart, “Province begins radical surgery on health system,” The Toronto Star, Wednesday, June 29, 2005, Page: A17
 “Some doctors in Ontario say there’s a downside to targeting specific medical problems in order to reduce waiting times for treatment,” World Report, Broadcast Date: Wednesday, December 14, 2005 Time: 08:00 EDT, Network: CBC Radio
 For a useful discussion of the purchaser-provider split and the privatization of British health care, see Allyson M. Pollock, NHS plc: The Privatization of Our Health Care, Verso, 2004.