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CIHR’s decision-making style, which resulted in it going ahead with changes to funding despite objections from Indigenous and non-Indigenous researchers, “is not consistent with the recommendations of the Truth and Reconciliation Commission,” says Rod McCormick, a Mohawk researcher and co-chair of the Aboriginal Health Research Steering Committee.

There is no recognition or provision for the fact that systemic policies, when applied across the board, can have damaging impacts for groups that are different,” McCormick told an emotionally charged meeting at the Wabano Centre for Aboriginal Health in Ottawa on Jan. 25.

In 2014/15, funding for Aboriginal health research was $31 million, down from $34 million at its annual peak 2004–2008, the Aboriginal Health Research Steering Committee reported.

McCormick and co-chair Frederic Wien, the principal investigator for the Atlantic Aboriginal Health Research Program, urged CIHR to revisit its changes and rebuild what Wien called “a respectful relationship with First Nations, Métis and Inuit people.” Given the crisis in the health and well-being of many of these communities, the researchers want CIHR to prioritize Aboriginal health research.

We have gone through major changes at CIHR. I do not deny that,” Beaudet said. “But I would deny ... that these changes are affecting particularly the Aboriginal community.”

Marlene Brant Castellano, co-director of research for the Royal Commission on Aboriginal Peoples, believes CIHR is out of step with the Truth and Reconciliation Commission’s recommendations.

Beaudet made the remarks just three days after the shootings at La Loche, Saskatchewan. The murder of two teenagers, a teacher and a teacher’s aide in the largely Dene community underscored for some attendees the crises in suicide, lack of mental health support and poverty that affect many Aboriginal youth and families.

Beaudet said Aboriginal health research is “extremely important” for CIHR, and its strategic investments will reflect that. CIHR has been working with the Aboriginal Health Research Steering Committee for 14 months and, according to the institute’s media specialist David Coulombe, is committed to “co-building research initiatives” that “will improve the health of Canada’s First Nations, Inuit and Métis peoples.”

While Beaudet acknowledged both the magnitude of the recent changes and the fact that the Aboriginal health research budget has “flatlined,” he said it has done so parallel to CIHR’s overall budget. CIHR’s billion-dollar annual federal budget has not increased since 2009, meaning that its spending power has declined by roughly 25% since then.

CIHR’s president denied any need for the federal agency to engage in reconciliation. “I would like to bring my personal views, not only those of CIHR, about the stormy weather we have been experiencing lately,” Dr. Alain Beaudet told attendees at the January meeting. “But not in the spirit of reconciliation, because I don’t think anything has been broken.”

The Aboriginal Health Research Steering Committee contends that CIHR disadvantages researchers working in Aboriginal health through recent changes such as scrapping an Aboriginal-specific peer review process, requiring matching funds for several granting programs, and reallocating almost half the open competition funding for stellar emerging and establishing scholars.

But Beaudet said the changes promote more “out-of-the-box” research that will enable Canada to achieve more international success. He also suggested that those critical of the new system are afraid of change, and advised researchers that “looking back doesn’t work.” Learning from the past is a critical Indigenous value. CIHR is starting to analyze the

results of its initial investments, but it will take seven years for the new system to take full effect and before “meaningful” figures result, Beaudet said. “We’ll work as quickly as we can, but we need the data. I’m saying ‘Yes, trust us,’ because if you look at CIHR’s record, we’ve done a lot, and we’ve done it in good faith.”

Most of the researchers and representatives of Aboriginal political organizations at the meeting did not seem inclined to trust Beaudet’s reassurances.

You’re really saying to this group, ‘Trust us.’ And I just want to remind you that there’s very little basis for trust,” said Scott Serson, a former deputy minister of Indian Affairs and Northern Development, now with Canadians for a New Partnership, a group working for a new relationship between Indigenous and other Canadians.

The Aboriginal Health Research Steering Committee asked CIHR to set aside half a day at the June meeting of its governing council to address these issues. In an online statement, Beaudet acknowledged the request for an in-depth discussion at “a future meeting” of the governing council. He also urged Indigenous health researchers and community members to apply as members of the new Institutes Advisory Board on Indigenous People’s Health and a new College of Reviewers.

Marlene Brant Castellano, co-director of research for the Royal Commission on Aboriginal Peoples and the Mohawk elder who closed the meeting, described Beaudet and CIHR’s response to the committee’s requests as “disconnected” from the prevailing political environment.

Castellano, who is revered as the first Aboriginal full professor at a Canadian university, brought many in the audience to tears. Instead of recognizing the need for a new relationship between Canada and its Indigenous peoples, Beaudet’s remarks echoed a too-familiar demand that Aboriginal researchers “get with” CIHR’s program because, eventually, they would discover it was good for them, Castellano said.

“We have 400 years as Indigenous people trying to make things work in other people’s agendas, and that is where we’ve gotten to the place now, where we still are, of watching our children dying,” she said, tears streaming down her cheeks.

Beaudet had already left the meeting before Castellano went to the podium, and the two CIHR vice-presidents who had stayed for most of the discussion left as she began to speak, citing prior commitments. Only Malcolm King, scientific director of CIHR’s Institute of Aboriginal Peoples’ Health and a member of the Mississaugas of the New Credit First Nation, remained for the duration of the meeting.

According to Coulombe, Beaudet had a phone conversation with Castellano on Jan. 29, and “agreed to continue working collaboratively with community representatives and leaders in the future.”

When we established our universal health care system more than 50 years ago, the average Ontarian was 27 years of age and less likely to be living with chronic and complex health issues. In contrast, 60 per cent of our total hospital days last year were amongst older Ontarians, particularly those living with multiple health issues, and with minimal social supports.

When these patients end up in hospitals, it becomes a particular challenge to get them back in their own homes. In fact, more than 14 per cent of Ontario's hospital beds are currently occupied by patients like these who cannot be discharged because we don't have the right types of services available in the community. By having to stay in hospital, these patients aren't getting the kind of care that they should. And by remaining in hospital, the cost of their care and cost to their overall health is much higher than it actually needs to be. The majority of these patients are waiting for less costly at-home care services through home and community care agencies, or care in more supervised or assisted living environments, such as nursing homes. We also know that too many older Ontarians are still sent to nursing homes when there isn't enough home care, which is less expensive, available. With these growing pressures coming to a head, now is the time to act and make sure that our province can continue to provide the high-quality care that Ontarians want, need and deserve.

It is time to invest aggressively in home and community care, nursing home and assisted living services, and other vital areas so that patients can stay healthy and independent in their communities for as long as possible and when hospitalized, be discharged quickly and safely to get quality care in their community.

We need to identify the right mix of services to ensure all Ontarians can get the right kinds of care where and when they need it. That means knowing the right number of beds needed in hospitals or long-term care homes, as well as the number of assisted living spaces, home care hours, and primary care and mental health services required to meet the needs of our aging population. Given the exploding need for different kinds of services, it also means we need to be innovative by creating new models of care.

While the government has recently acknowledged the importance of robust health-service capacity planning, neither we nor any other Canadian jurisdiction currently has such a plan. This is worrisome because what we do know with absolute certainty is that the number of older Ontarians will double over the next two decades. With service demands growing rapidly at the same time that the system moves to further contain cost growth, we owe it to patients and clients to meet their changing health care needs not only for today but for the decades still to come.

Ontario needs clear-eyed and effective long-term planning to ensure its health care system has the ability meet the evolving health care needs of Ontarians. Until we know exactly what services the people of Ontario need, our system won't have the long-term plan required to meet them. Dr. Samir Sinha is director of geriatrics at Mount Sinai and the University Health Network Hospitals and provincial lead of Ontario's Seniors Strategy. Anthony Dale is president and CEO of the Ontario Hospital Association.

In the letter to Timmings, lawyer Michael Polvere of Siskinds wrote, "While we encourage all honest and fair debate on the issues, defamatory and untrue statements made of and concerning our client, the LHSC, will not be tolerated and will be met with swift action. The LHSC intends to hold both RNAO and yourself personally responsible for the conduct of this meeting." At the 6:30 p.m. meeting at Wolf Performance Hall in the Central Library, Timmings will lead discussion on a nurses' association report that claims cash-strapped hospitals are cutting registered nurses and replacing them with less qualified and lower-paid staff to the detriment of patients. "These (changes) are detrimental to Ontarians, to nurses, and to the future of health and health care in Ontario," conclude authors of the report Mind the Safety Gap in Health System Transformation: Reclaiming the Role of the RN. No one should be muzzled from discussing key health issues and LHSC's efforts should be addressed by Ontario Health Minister Eric Hoskins, Grinspun said. Hoskins couldn't be reached for comment Thursday. Nor could officials at LHSC. Earlier this year, Glendining refused to comment publicly on Burkoski's firing but defended the hospital in internal memos that insisted that the nurses' association had told a one-sided story and that safety was always a priority.

Allan said similar provincewide campaigns have had significant impacts in the past, such as stopping health-care privatization plans. He said the most recent referendum the Ontario coalition organized pertained to allowing private clinics to conduct some hospital surgeries, "and we collected 100,000 votes on an issue that I don't think is quite as well known as the cuts to our hospitals." "This is a much bigger issue, and I think we can get an even bigger vote," Allan said. "We need to collect the votes, send them offto the legislature, we need to do it collectively right across the province and send a very loud message. I think we can send an extremely loud message in Port Colborne because of the circumstances that we're looking at here." The meeting was organized to discuss the provincial government's plans to close hospitals in Port Colborne, Welland and Fort Erie and replace them with a single new hospital in Niagara Falls.

Niagara Health System in an e-mail to The Tribune Tuesday said Angela Zangari, executive vice-president and project lead, and NHS president Suzanne Johnston "have been across all NHS sites over the past few weeks sharing the preferred designs for a new south hospital at Lyons Creek and Montrose roads and a new ambulatory care/urgent care and longterm care development in Welland at King and Third streets. "We believe it is important to share information with our staff, many of whom have been engaged in planning activity for the projects. "Dr. Johnston is committed to working with staffto discuss planning on a regular basis. In addition she will be continuing to meet with community leaders to plan forward." At Wednesday' night's coalition meeting, several residents shared concerns about access to health-care services, including Aubrey Foley. "I don't want to offend anyone from Welland, but I live in Port Colborne, my hospital is in Port Colborne and this is where it should remain," the 71-year-old said.

He said his city of 19,000 people has a "deplorable walk-in service for health care." "It is not acceptable. There is no reason for it to be the way it is today," he said, while noting Dunnville, a town of 11,000 people, has a "fully functional hospital with free parking." "If Dunnville can do that, we can do this very easily," Foley said. Former mayor and regional councillor Bob Saracino said he will do whatever he can to save the Welland hospital, but the community must also work together to keep the urgent care centre running in Port Colborne. "When it comes to health, we must be one," he said.

Saracino said health care "is not a privilege, but it is a fundamental right that we have under the Canada Health Act." While Hotte said she agrees Niagara Falls needs a new hospital, "it should not be at the expense of people in Port Colborne, Welland, Wainfleet, Pelham - over 94,000 people losing access to hospital services." "No way! We need to keep the hospitals open and access to services," Hotte said.

About 80 people attend Wednesday night's meeting at Guild Hall about the planned closure of Port Colborne hospital. • Photos By Allan Benner, Tribune Staff / Ontario Health Coalition board member Doug Allan speaks at a meeting to discuss efforts to save Port Colborne hospital.

For health authorities to avoid a financial penalty, 90 per cent of their hip patients must be treated within 26 weeks, 90 per cent of knee patients within 26 weeks, and 90 per cent of cataract patients within 16 weeks.

there is a drawback to the way the penalties are applied, Dr. Vertesi said

They are all or nothing, he said, meaning a health authority that falls only a few patients short of the targets is liable to be subject to the full holdback.

“It’s not that there shouldn’t be any consequences, but they are a very blunt tool. If you’re not careful and use them in the wrong way, you may get results you don’t want.” Published on Monday, Feb. 06, 2012 10:46PM EST

It would have been more productive, however, had more members of the general public attended. People who did not attend can still answer a survey online, through May 29, at www.surveymonkey.com/s/healthcaretomorrow. BGH officials at the event were eager to remind people that another open house, this one specific to the future of the local hospital, is scheduled for Tuesday, June 2, from 5 p.m. to 8 p.m. at the 1000 Islands Mall. The June 2 meeting will give the public a chance to hear directly from BGH officials about the challenges the hospital faces as it tries to address a $1.9-million shortfall. BGH officials have pledged to listen to the public on how it will deal with that shortfall. They have also promised that, while service delivery may be changed as efficiencies are sought, the services themselves will not be reduced. This is an important opportunity -one of many, we hope -to show them the public is watching. This is not a meeting to skip. @RipNTearRon on Twitter

were meeting the guideline, while 33 facilities were exceeding it. (Information is missing on another 10 for a variety of reasons. For example, some were new.) The directory's data shows that a quarter of seniors in the homes have a diagnosis of depression and nearly one-third are being given anti-psychotic medication without a diagnosis of psychosis.

Your questions show we have some work to do here," she said. "I will specifically be writing to each Health Authority and the government on this issue. We have a target of care hours and here's how many of your facilities are at that or under that." Mackenzie said her office will also analyze the Residential Care Facilities Quick Fact directory data to determine whether facilities with low staffing levels may also have more seniors who are depressed or who are prescribed antipsychotics medication. She also wants to study whether these homes offer fewer amenities to boost quality of life such as recreational and occupational therapy. Mackenzie said the Quick Facts Directory, available online, provides numbers to back anecdotal evidence that quality of care has declined in many B.C. seniors homes. The directory will be updated annually, but does not include data on private nursing homes that receive no government funding.

"Anecdotally, everyone was saying hours (for staff) were being cut, but now you have quantitive evidence. For policy shifts (in government), they want to know the magnitude of the issue. Let's have a discussion on how we can fix this. Before you can deal with what homes are not providing recreational therapy and OT (occupational therapy), for instance, you have to fix the hours of care first," said Mackenzie. Whiteside said the figures showing the vast majority of government-funded homes are below ministry staffing guidelines prove what HEU members have been saying for years - that they are rushed in trying to care for seniors in nursing homes and concerned that seniors are suffering and workers are placed in dangerous situations when a senior acts out violently.

A recent Vancouver Sun series on violence in nursing homes found more than 1,000 physical assaults by seniors in long-term care facilities last year. And in the past four years in B.C., 16 seniors in care have been killed by other seniors suffering from dementia. "There's simply not enough time for them (care aides) to do their job and provide the care seniors need. When we establish what the level of care needed is, it needs to be mandatory. Clearly, there needs to be more strenuous accountability in this system for seniors - many of whom are frail," said Whiteside. Nor was she surprised to find 74 per cent of the privately owned and operated businesses failed to meet ministry guidelines. "The system is set up so Health Authorities are contracting with private providers and some of those private providers are subcontracting out some of the care to other contractors and at each phase there needs to be a profit made. It's not the kind of system to have for frail seniors. It's quite shocking to think this is the system we have for them," said Whiteside.

A Vancouver Sun request to interview Health Minister Terry Lake was not granted. However, the ministry sent an email stating there are no plans to introduce mandatory staffing levels. The recommended 3.36 direct care hours is a number used "as a starting point for planning decisions," the email said. "The standard that we want care providers to meet is high quality care at whatever level is most appropriate for an individual patient," the ministry email states. "Direct care hours are dependent on the individual's needs and are determined through a comprehensive assessment process involving the client, their family and staff. Experts all agree that having a legislated or policy requirement for staffing ratios and staffing hours is not appropriate, because of the complexity of patient needs." Daniel Fontaine, the CEO of the B.C. Care Providers Association, whose members represent approximately 60 per cent of the government's contracted-out beds, said home operators would be happy to provide 3.36 direct care hours, but the government funding isn't enough to reach this level.

We can only do what we are funded to do," said Fontaine. "While the government and health authorities are trying to bring those on the lower (staffing) levels up, it's been a slow process." One of the solutions could be to take some of the money spent in the acute care system and shift it into continuing care so seniors in long-term care facilities benefit, Fontaine said. Lorri Chmilar, who retired from nursing last year after working mainly for the Interior Health Authority, said the most stressful place she worked during her career was nine months spent in geriatric care. "Anyone who has worked in public care facilities has seen a decrease in staffing, decrease in activities, and decrease in quality of meals. What has increased is the amount of time in recording statistics, and basically CYA (cover your ass)," she said. "Understaffing is also a result of the poor mix of residents. It only takes one or two residents with severe dementia or severe physical impairments to increase the workload significantly to the detriment of the rest. To increase staffat this point, or to transfer a resident to a different care area is a major undertaking that requires much justifying and time. Nurses are derided for asking for extra assistance, if there is any to be had, and roadblocks to transfers are numerous. I fear for my family, and others, and the grey wave of us to come."

THE NUMBERS DRUGS WITHOUT DIAGNOSIS In B.C. facilities, an average of 31 per cent of residents were given antipsychotics without a diagnosis of psychosis. 133 facilities were above this average. 11 were at the average.

136 were below the average, but just one reported zero cases of providing antipsychotics without a diagnosis of psychosis. DAILY PHYSICAL RESTRAINTS In B.C. facilities, an average of 11 per cent of residents have daily physical restraints placed upon them. 116 facilities are above the average.

9 are at the average. 155 are below the average, of which 27 made no use of physical restraints. Source: Office of the Seniors Advocate, Province of B.C. © 2016 Postmedia Network Inc. All rights reserved.

In February 2012, Mr. Lister raised concerns with his employer and alleged the presence of asbestos on pipes in the nursing home. The Lodge brought in environmental consultants, but Mr. Lister questioned their qualifications and made statements challenging the accuracy of the expert advice they provided as to health and safety.

In March 2012, Mr. Lister attended a general staff meeting where he reportedly made inappropriate gestures and fell asleep. The employer then sent a warning letter to him, which was placed on his personnel file. A few months later, in the summer of 2012, Mr. Lister brought a tomahawk axe to work and, for this action, was suspended for 1.5 days as "progressive discipline." In

the Fall of 2012, Management called a meeting with Mr. Lister for which he declined union representation when offered. Mr. Lister was instructed by the Employer that he would not be permitted to return to work until he had a psychiatric evaluation. He was immediately suspended, indefinitely, without pay, and escorted from the property. Mr. Lister was ultimately assessed by a psychiatrist, who determined that he did not pose a danger to himself or others; however, he missed over twenty (20) days of work without pay before being cleared.

CUPE filed three (3) grievances, two of which were the subject of the judicial review, these were: (1) alleging that the employer violated the collective agreement by not having a union representative present at the suspension meeting; and (2) that the employer had violated the collective agreement by suspending the grievor pending a psychiatric evaluation, without valid reason and without pay. The (3) third grievance concerned the 1.5 day

suspension of Mr. Lister for bringing a tomahawk axe to work. On the third issue, the arbitrator concluded that the suspension was reasonable and the Lodge did not seek judicial review. The arbitrator held that the Lodge had violated the collective agreement by not ensuring a union representative had been in attendance at the meeting with Mr. Lister. He had been told that he did not need such representation, but he clearly did. The Lodge had also violated the collective agreement by suspending Mr. Lister without cause and for over 20 days, which was contrary to the collective agreement.

However, there was significant evidence that the suspension was, in fact, disciplinary. Letters had been issued by the employer previously warning Mr. Lister of further "disciplinary action", Mr. Lister was escorted from the premises and Union representation had been offered at the meeting. Further, the suspension resulted in the grievor suffering a financial penalty,

employer argued it did not intend to punish Mr. Lister and fully expected a psychiatrist would find him unfit to return to work; however, since Mr. Lister had no sick days left, he was simply "suspended" without pay, pending the evaluation.

The Decision On judicial review, the New Brunswick Court of Queen's Bench upheld the arbitrator's refusal to accept the employer's argument that the suspension, due to mental health concerns was a "medical leave", and not a disciplinary action. The

as he was unable to access sick benefits and received no pay. Ultimately, the Court of Queen's Bench concluded that the arbitrator was justified in finding that the employer had disciplined Mr. Lister by suspending him and prohibiting his return to work pending a clear psychiatric evaluation, and that this was a violation of the collective agreement.

What This Means For Employers With the exception of certain safety-sensitive industries where a bona fide occupational requirement can be established, employers cannot discipline, suspend or dismiss employees suffering from a mental illness or disability. Employers have a legal duty under human rights legislation and/or collective agreements to accommodate all disability, up to the point of undue hardship. Unions, where applicable, also have legal duties within the

accommodation process and can be of assistance in navigating "difficult" employee behaviour, including mental health issues where such employees may pose a risk not only to themselves, but the broader workplace. Occupational health and safety legislation also requires employers to provide a safe working environment for their

employees. Under certain conditions, with the proper evidence and context, employers may need to remove an employee with a confirmed mental illness to protect against harm to others or themselves. In such specific circumstances, an employer might be justified in preventing an employee from returning to the workplace until medical clearance is confirmed. The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances. Ms Leah Ferguson

Cox & Palmer Suite 400 Phoenix Square 371 Queen Street Fredericton NB CANADA Tel: 902421 6262 Fax: 902421 3130 E-mail: kbehie@coxandpalmer.com URL: www.coxandpalmerlaw.com

Those changes included cutting wait times, improving home care, electronic records and telehealth, better access to care in the North, a national pharmaceuticals strategy, improvements in prevention in public health and accountability and better reporting to Canadians. Philpott's assessment Tuesday was the provinces had intended to live up to their commitments but that it hadn't happened. "The transformation to the system didn't follow," she said. Philpott said Canadians want to be able to measure where new money is going, such as the number of hours of therapy delivered in a mental health program or the number of additional home care visits added. Manitoba Health Minister Kelvin Goertzen said in a later conference call he agrees there needs to be more reform and innovation, particularly when it comes to accountability and meeting specific performance targets. "I would take exception that there hasn't been any innovation," he said. "Could there have been more? Sure."

Goertzen said Manitoba will be announcing more health-care targets shortly, with plans to better account for the dollars spent. He said additional funding for home care or mental health would be welcome but Ottawa needs to be a better partner on the day-to-day business of health-care delivery, and the three per cent increase isn't enough. The provinces have long complained Ottawa was to contribute half the cost of medicare but its contribution is now around one-fifth. They want the accord to move Ottawa to contributing 25 per cent. "We didn't get that commitment today," said Goertzen. The provinces want to discuss the health accord with Prime Minister Justin Trudeau when they all meet in Ottawa in December. Trudeau called that meeting to discuss climate change and the new carbon price he is requiring all provinces to impose. Health care is not currently on the agenda. mia.rabson@freepress.mb.ca

the impact of Liberal health-care policy in southern Ontario is "bad enough." The model Mehra said the province is using to centralize services into fewer communities is especially detrimental to the North. "That doesn't work for the south," she added. "It definitely, in no way, works for Northern Ontario." The state of Northern health care was brought to the floor of Queen's Park this week when, on Wednesday during Question Period, NDP health critic France Gélinas called on the government to stop continued cuts to care in the region. Funding based on volumes doesn't jibe with regional population distributions, Mehra said. "It just doesn't make any sense at all," she said, adding Northern Ontario has many common complaints with small, rural southern Ontario communities.

The coalition argues the entire Ontario system has received short shrift for years and is below the Canadian per capita average by about $350 per person. The provincial Liberals ended a four-year hospital base funding freeze in its latest budget, pledging to spend $60 million on hospital budgets, along with $75 million for palliative care and $130 million for cancer care. The Ontario Health Coalition - and Sault and Area Health Coalition - are not impressed. The local group argues on a regular bases, 22 admitted patients often wait in SAH's Emergency Department for inpatient beds and admitted patients stay in emergency for as long as five days. Patients are lined along hallways on the floors or put in areas that were designed to be stretcher storage areas or lounges with no call buttons, oxygen, out of the nurses' usual treatment areas. Late last month, the Ontario Health Coalition launched an Ontario-wide, unofficial referendum to raise awareness about what it contends is a system in critical condition. The unofficial referendum asks Ontarians if they're for or against the idea: "Ontario's government must stop the cuts to our community hospitals and restore services, funding and staffto meet our communities' needs for care." Ballot boxes will be distributed to businesses, workplaces and community

centres across the province before May 28, when votes will be tallied and presented to Premier Kathleen Wynne. "We have to make it so visible, and so impossible to ignore, the widespread public opposition to the cuts to local public hospitals so the province cannot continue to see all those cuts through," Mehra said. Similar public OHC-led lobbying helped limit and "significantly" change policy in a past Sault Area Hospital bid to usher in publicprivate partnerships (P3s), she added. "The referendum is a way to make that so visible, so impossible to ignore by the provincial government, that we actually stop the cuts," Mehra said. Other speakers Thursday included Sault coalition member Peter Deluca, who spoke of the many challenges his elderly parents have endured thanks to what he dubbed less-than-stellar hospital experiences. "We deserve the truth, we deserve answers, not just political talk," said Deluca, adding concerned citizens must band together in order to prompt change and halt healthcare cuts.

Sharon Richer, of Ontario Council of Hospital Unions/CUPE, said as a Health Sciences North employee, she's seen "first-hand" how cuts affect health care. "There won't be change if we don't make a ripple," she said. Laurie Lessard-Brown, president of Unifor Local 1359, told the meeting of how SAH's recent "wiping out" of the personal support worker classification is wreaking havoc on staff and patients, alike. Registered nurses and registered practical nurse must now pick up the slack, she added. "Morale is lowest I've ever seen," Lessard-Brown said. And, as recent as last Tuesday, Unifor learned of a further four full-time RPN positions being cut while supervisor positions were being added. "Cutting front-line workers is not acceptable," Lessard-Brown said. jougler@postmedia.com On Twitter: @JeffreyOugler © 2016 Postmedia Network Inc. All rights reserved.

Natalie Mehra, Ontario Health Coalition executive director, decries what she describes as the profound lack of funding being divvied out to Ontario hospitals during a town hall meeting Thursday evening, hosted by the Sault and Area Health Coalition at Royal Canadian Legion, Branch 25.

"I go help mothers with their sick children while I leave mine at home," Saoud said. "I can't see how I can do more." Saoud has three young children. She devotes 60 per cent of her workweek to a Montreal hospital's emergency department - irregular hours that include evening and weekend shifts - while the rest of her schedule is split between a walk-in clinic and what's known as "dépannage," replacing doctors in Quebec's more remote regions at least once a month. What she wants is more time for her job as a mother - helping with their homework and sharing meals - and not have to meet "an impossible" quota of following 1,500 patients, as the original Bill 20 would have required of each family doctor.

I am already at my maximum," said Saoud. And so, she has applied for a licence to practise outside Quebec. Nearly 24 per cent of Quebecers are on a waiting list or desperately searching for a family doctor. The crisis is rooted in a 1990s provincial government plan to save money by encouraging doctors to retire early. Staffing shortages ensued, and family doctors were obliged to fill the gaps by working outside their clinics in hospitals and far-flung regions. Quebec has attempted, with little success, to improve primary care over the last two decades by expanding community health clinics (CLSCs) and creating pools of doctors known as Groupes de médecine de famille (GMF) but both limped along under budget constraints and heavy bureaucracy. Barrette contends that the province has more than enough physicians to meet its needs, but that a profound structural change is needed.

He presented Bill 20 last fall as his road map to ensure that every Quebecer has a regular doctor. But the bill's punitive measures sparked widespread discontent among doctors against what they called a one-size-fits all, state-controlled, conveyor-belt approach to medicine. Doctors were further incensed at Barrette's assertion that doctors are not productive enough - which they saw as being accused of laziness - and frustrated at being blamed for a broken health system.

Like Saoud, many doctors prepared exit plans - from retiring to leaving the province. Some med students, many of whom were actively recruited to shore up Quebec's supply of family doctors, began reconsidering family medicine - or simply leaving to do their residency out-of-province, according to the Fédération des médecins résidents du Québec. Saoud was heading home to her sick daughter on Monday when Barrette announced he had cut a deal with the provincial federation of family physicians to exempt them from Bill 20 - temporarily. There would be no quotas and no penalties, Barrette said, as long as family physicians were able to collectively ensure that 85 per cent of Quebecers had a family doctor by the end of 2017. But Saoud says the change will not keep her here. And she's not alone.

The buzz among disillusioned physicians is that "everyone has a Plan B." And while the bill's delay has eased tensions a notch, some doctors are saying the two-year delay simply means they now have until 2017 to prepare a better exit. Bill 20 remains a guillotine above the heads of doctors. "Most definitely, there are physicians investing in Ontario licences and poised to leave if Bill 20 passes. I myself may have to leave," family physician Maggie O'Dell, who works at the Wakefield Family Medical Centre near the Ontario border, said before the bill was modified. And after Barrette backtracked, she had this to say: "It's nice to have reprieve, so it's a relief - for now ... a reason for many to hold back on pulling up stakes in the short term."

Montreal family physician Fahimy Saoud hated leaving her sick 5-year-old in someone else's care this week, but it was her turn to staffa walk-in clinic and she didn't want to let those patients down. But as the day wore on, Saoud kept hearing her daughter's plea when she left the house: "Who will take care of me?" So on Monday, after seeing everyone in the waiting room, Saoud left the clinic early; her daughter needed her as much as her patients did.

The group's recent survey - 204 of its members responded - indicated that Bill 20's sanctions would backfire. While the survey was taken three days before Barrette modified Bill 20, Duong said the results reveal that doctors, in particular those whose mother tongue is English, are at risk of leaving the province. Among the 134 francophone doctors polled about their intentions if Bill 20 were applied, 32 per cent said they would resign from hospitals, 12 per cent said they would leave Quebec and another nine per cent would go into private care.

Among the 70 anglophone respondents, seven said they already sent letters of resignations to their hospitals (it's not clear whether they are keeping their office family practice) and among the remaining 63 doctors, 34 - more than half - said they planned to leave Quebec. Another seven said they would retire early, seven would move to the private system and three would stop working as family doctors. It's a small sample, Duong conceded, but the study is nonetheless alarming.

We are worried that doctors will leave," Duong said, noting that every year, more doctors are opting out of the provincial insurance board (RAMQ), meaning they are no longer on the public payroll, though it's not clear whether they went to private practice or left Quebec. RAMQ representative Marc Lortie confirmed this week that 246 family physicians dropped out of RAMQ between May 2014 and May 2015, up from 204 the previous year and 187 in 2012-2013.

In the wake of Monday's announcement to put offBill 20's sanctions, many doctors remain skeptical of Barrette's 85-per-cent target, Duong says, "because it's far too ambitious a goal." Whatever doctors' efforts, Duong says, the reform will fail if the government doesn't help them do their jobs - for example, by abolishing mandatory hospital work. Others suggest the crisis between the province's doctors and Quebec's health minister is over. Bill 20 was heavy-handed, they argue, but if it leads to doctors taking on more patients it will have been a successful negotiating tool. Dr. Yoanna Skrobik, a critical care researcher and adjunct professor at McGill University's department of medicine, is among those who wholeheartedly support the Barrette reform.

It's the most dramatic change in the history of Quebec's health system, and the best thing that's ever happened to patients," said Skrobik, who worked side by side with Barrette at Maisonneuve-Rosemont Hospital in the early 2000s, when Barrette was chief of radiology and she was an intensivecare physician. She said that if 85 per cent of Quebecers have a family doctor, the quality of health care in the province will be much improved. Doctors may be offended by Barrette's manner, and by what they see as an attack on their autonomy, Skrobik said, "but it's also true that he puts patient care in the forefront."

But Saoud also has priorities. She earned her first medical degree in Haiti, then had to obtain it again after emigrating to Montreal. There's a saying among those who work in the ER, she said: "We know when we go in, but we don't know when we will leave." Saoud, who won the Nadine St-Pierre Award for her research as a resident in family medicine in 2009, still loves being a doctor. "It can be frustrating, but it's really gratifying work. Helping someone is really the cherry on the sundae. But my priority is not that." She would rather not force the children to uproot, but she's skeptical doctors can meet the demands of the health reform. And possible sanctions in two years could force her to to make a tough choice.

"My male colleagues don't have that issue. The bill is discriminatory. I'm just asking for the right to be a mother and not simply a doctor." With her permit application process in motion, Saoud says she will go wherever her licence takes her. cfidelman@montrealgazette.com twitter.com/HealthIssues

Medical students from four major Quebec universities demonstrate against Bill 20 in March near the legislature in Quebec City. • VINCENZO D'ALTO, MONTREAL GAZETTE / Dr. Fanny Hersson-Edery, left, at a diabetes clinic she runs with nurse Jen Reoch. Hersson has a full schedule, from research to teaching and seeing patients.

Long-term care: Invest in infrastructure so there is an adequate number of beds, and so they are affordable, particularly for seniors with specialized needs, such as those with dementia. Palliative care: Promote advance-care planning and ensure everyone gets palliative care at the end of life. In a wide-ranging discussion, delegates to the CMA meeting identified a number of specific issues that are hampering the provision of care to seniors with chronic health conditions, such as the lack of electronic health records, the way health-care delivery is siloed in Canada, the absence of pharmacare, physician payment schemes that reward volume rather than quality of care, the lack of training in geriatrics and a lacklustre commitment to patient-centred care.

The overarching theme was that if care is going to be improved for the burgeoning population of seniors, it must begin with better co-ordination. Dr. David Naylor, who headed the federal Advisory Panel on Healthcare Innovation, also stressed this as an essential element of reform. In a keynote address to the CMA meeting, he said that while Canadians love their medicare system - at least in theory - the reality is that "the scope is narrow and performance is middling." Dr. Naylor said the main reason Canadians don't get good value for money when it comes to health spending is a lack of co-ordination of care. "The critical factor is integration of services," he said.

Right now, far too many patients, especially seniors with chronic conditions, are being cared for in hospitals rather than in the community and their care is disjointed, the CMA's report notes. Fixing that will, among other things, require a reorganization of roles between various health professions, including physicians, nurses and pharmacists. "All health-care professionals are going to have to do their bit to deal with this grey tsunami," he said, stressing that many innovative solutions have been put in place across the country, but they are too rarely scaled up.

Dr. Naylor said policy-makers, and federal politicians in particular, need to take a leadership role to ensure this happens. Dr. Simpson of the CMA also called for federal political parties to commit to a seniors' strategy during the current election campaign, and said he is confident they will. "We know they're thinking about it. We know their hearts are in the right place," he said. "Now we want them to start talking about seniors' health care in the context of the election campaign so people can cast their votes accordingly."

There are many other health issues begging for more attention. Advocates of pharmacare and physician-assisted suicide are pushing hard to get their concerns front and centre. But there has been little discussion so far about health care during the campaign, despite the fact that time and time again it ranks as the top issue of concern among voters. The exception is Green Party Leader Elizabeth May. On Wednesday, she announced her party's strategy for seniors, including a universal drug program and a guaranteed livable income.

Meantime, health-care professionals like Sinha are left to deal with the fallout from the widening cracks in the system. "The issue my patients struggle with the most is getting access to home and community care services. I spend way too much of my time trying to navigate the complicated system on behalf of my patients to make sure we can cobble together what they may need," he said. Physicians are equally worried. More than 500 members of the Canadian Medical Association gathered last week for their annual meeting in Halifax where they reiterated their call for the creation of a national seniors' strategy.

Outgoing president Dr. Chris Simpson told the gathering that there is widespread public support for a seniors strategy to meet the growing health needs of an aging population, but that politicians have been disappointingly silent on the issue. In his closing speech, Simpson warned that doctors are not going to let politicians off the hook. "We will be tracking commitments made by the parties, and we'll publish the results at the end of the campaign so that Canadians who are worried about seniors can make an informed decision when they're at the ballot box." Alan Freeman, Senior Fellow at the University of Ottawa's Graduate School of Public and International Affairs, isn't surprised that the issue of health care has not received much attention.

Any substantive discussion would involve mention of transfer payments and equalization formulas - complicated topics that make people's eyes glaze over. That absence of debate serves Conservative Leader Stephen Harper just fine, Freeman contended. "This works out quite well from the federal government's point of view, especially Harper's point of view, in that he's not interested in an activist role for the federal government in health care," Freeman said.

A similar sentiment was expressed in a recent editorial in the Canadian Medical Association Journal. Deputy editor Dr. Matthew Stanbrook wrote that the federal government seems to be trying to get out of the health-care business. "Recent years have seen Canada's health-care system race to the bottom of quality rankings compared with other nations that have prudently invested in maintaining a strong social safety net," he wrote, warning that the most complex problems in the health-care system cannot be solved without federal leadership.

Ontario Health Minister Eric Hoskins agrees that Ottawa's hands-off approach is hurting the health system. He's specifically concerned about the Conservative government's plan to reduce the rate of increases in health transfers to the provinces. "As Canadians, we owe it to ourselves and to our children to begin a frank and earnest conversation about the state of our health-care system and what a modern health-care system should look like in 2015 and beyond," Hoskins said in an email to the Star. "It's up to all of us - both political leaders and the citizens we represent - to speak up and ensure it has a place in that electoral debate." Conservative party spokesperson Stephen Lecce noted that just Stephen Harper promised to maintain funding for the Canadian Partnership Against Cancer, an agency devoted to combating the disease.

"Since 2006, under prime minister Harper's leadership, health transfers have increased by 70 per cent while balancing the budget and keeping taxes low. Federal funding is a record levels, and will reach $40 billion annually by end of decade, providing certainty and stability, and an enhanced quality of life for Canadians," he said. Barry Kay, a political science professor at Wilfrid Laurier University, expects that in a long campaign, the parties are biding their time before getting into substantive debates.

"I think the leaders are holding their fire till later on when the campaign moves beyond the 'spring training' phase and more people are watching," he said.

Mr. Georgiou, 51, is a long-time senior public servant. Between 2006 and 2012, he held various executive positions at Infrastructure Ontario, the procurement agency that was set up to administer the McGuinty government's ambitious plans to restore the province's outdated infrastructure through public-private partnerships. He was a project manager on the construction of several major projects, including some of the facilities for this summer's Pan Am and Parapan Games, eventually rising to the role of chief administrative officer. How he ended up admitting he issued false invoices - and why that information was not passed on by at least one of his former colleagues at Infrastructure Ontario - dates back to 2009, after a whistleblower complained to management at York about questionable invoices.

Court records show the scheme required Mr. Georgiou to invoice the university, through two family-owned companies, for work that those companies never performed. After cashing York's cheques, he passed on about $40,000 of the total $65,000 paid by York to an intermediary who was connected to a facilities official at the university. Mr. Georgiou said he kept $25,000 to declare for income tax purposes. "Once these events came to light, I fully co-operated with the authorities and counsel for York University, and I assisted them with their investigation. In addition, I ensured that the party who requested the invoices, repaid the entire amount to York University," he said in the statement. He did not address questions about what he told St. Michael's, if anything, about his role in the scheme.

St. Michael's and Infrastructure Ontario have ordered forensic audits. "These swift and prudent actions have been taken by the Board of Directors and Management to preserve and protect the public trust invested in St. Michael's Hospital," a statement from St. Michael's said. In its own statement, Infrastructure Ontario said it was "very troubled" by some of the facts The Globe presented to four of its officials in an interview. "The activity in question goes against everything [Infrastructure Ontario] stands for," said Bert Clark, the agency's chief executive, and Linda Robinson, vice-chair of Infrastructure Ontario's board. Mr. Georgiou, who has been placed on a leave of absence from the hospital, said in an e-mail that The Globe had not provided him enough time to give proper answers to about 40 questions it e-mailed to him last Wednesday. In a statement, he said he never profited from the "exercise" at York and stressed that he was never charged criminally for his role in the false invoice scheme.

York investigated and concluded it had been the victim of a $1.2-million kickback scheme involving false invoices for nonexistent construction and maintenance work. A forensic audit determined that between 2007 and 2010, the university cut cheques to eight different companies for services that were never rendered. The York investigation found that two of those companies, Arsenal Facilities Consultants Inc. and Toronto Engineering Company, were connected to Mr. Georgiou. (He was the listed officer and director of AFC, and the other company was owned by his wife and her parents.) Mr. Georgiou and his lawyer, Gary Clewley, agreed to meet with auditors in February of 2011, and Mr. Georgiou admitted writing three false invoices totalling $64,800 between the two companies. The Globe has obtained a transcript of this meeting, which was marked "confidential" but included in court filings. Mr. Georgiou created paperwork showing that AFC did $22,000 worth of door lock repairs in November, 2007. In February, and then again in April, 2008, he drew up documents claiming that TECO completed a total of $42,800 worth of watermain work.

He wrote these invoices, he told investigators, at the request of a friend who had nothing to do with the university, a parking industry executive named Luigi Lato. According to Mr. Georgiou, Mr. Lato told him maintenance work had been performed and he was hoping Mr. Georgiou could create invoices for that work. But for reasons Mr. Lato never explained, Mr. Georgiou said, whoever did the work did not issue their own invoices. Mr. Georgiou said he believed Mr. Lato was doing a "favour" for a friend at York who needed to pay for the work. A lawyer and an auditor for York pressed Mr. Georgiou on why the companies that actually did this work would not, or could not, issue invoices, and Mr. Georgiou said he did not know.

"There were no details provided to me," he explained at one point. Pressed further, he said, "I didn't ask any questions." York paid AFC and TECO, but Mr. Georgiou told investigators he did not keep the money. He withheld about $25,000 to declare as income tax for both companies, which he said he paid. As for the rest of the money, he made two trips to see Mr. Lato in which he paid him a total of about $40,000 in cash. Mr. Lato could not be reached for comment.

William McDowell, a lawyer acting for York, asked Mr. Georgiou how the teller at his bank reacted when he withdrew $14,500 in cash for Mr. Lato's first instalment: "Doesn't your banker kind of squint when you go in and ask for $14,500 in cash?" Mr. Georgiou replied: "I didn't go into the bank and ask for $14,500 in cash, you know, like in one shot. I had, you know, some cash at home, went to the bank for some cash..." About a year later, on Jan. 26, 2012, York filed a statement of claim against all of the people and companies it believed had defrauded the university, including Mr. Georgiou. The same day, the university's general counsel, Harriet Lewis, met with a senior executive at Infrastructure Ontario, Bill Ralph, who at the time was the procurement agency's chief risk officer, both York and IO said in separate statements. Ms. Lewis informed Mr. Ralph that York had launched a lawsuit against Mr. Georgiou and others because of what the internal investigation uncovered.

Mr. Ralph did not respond to requests for comment. Two weeks after the meeting, Mr. Georgiou suddenly resigned. A few days later, the CEO of Infrastructure Ontario, David Livingston, announced in a company-wide e-mail that Mr. Georgiou was "leaving." The departure e-mail made reference to "various personal and family matters" Mr. Georgiou needed to address. "I know it was a tough decision for him, but I admire him for making it." Mr. Livingston did not respond to repeated requests for comment e-mailed to him and to his lawyer. After leaving IO, Mr. Livingston was appointed chief of staff in May, 2012, to Dalton McGuinty, then premier of Ontario. Mr. Livingston has been accused by Ontario Provincial Police of orchestrating a plan to purge government records after the controversial cancellation of two power plants. He has denied through his lawyer that he did anything wrong.

Employment lawyer Natalie MacDonald said a chief risk officer should give the board of directors any information that could damage the organization's reputation. A risk officer has a "duty to inform the board so it can make an informed decision," Ms. MacDonald said, speaking generally. But according to Infrastructure Ontario's organization chart, the chief risk officer reports directly to the CEO rather than to the board. In an interview last Wednesday, Ms. Robinson, the board vicechair, said the news that Mr. Georgiou had, at one time, been named a defendant in the lawsuit and admitted writing false invoices never made its way to the agency's board.

In April of 2012, Mr. Georgiou and Mr. Lato signed a settlement agreement with York that required them to pay restitution - the amount has not been disclosed in public documents - which Mr. Georgiou said in his statement to The Globe was covered by the "party" who requested the invoices. One of the conditions of the settlement is that York "shall not make any statements to the media" about the agreement or about allegations levelled in York's claim, except to say that Mr. Georgiou co-operated.

Seven months later, St. Michael's board meeting minutes show that it had identified a preferred candidate to replace its chief administrative officer, and in the New Year, Mr. Georgiou officially started his new job. In its statement, St. Michael's said an external search firm was enlisted to identify Mr. Georgiou, and a separate firm conducted reference interviews. The issues at York were "never disclosed by Mr. Georgiou," St. Michael's statement said.

In his statement to The Globe, Mr. Georgiou said he has led the hospital in securing government funding, as well as capital redevelopment funding. "During my tenure at St. Michael's we have achieved tremendous results for the hospital both in the excellence of our hospital's performance as well in the success of our redevelopment project."