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The document is expected to propose shifting much of the CCACs' home-care planning and oversight roles to the 14 Local Health Integration Networks (LHINs) that now are responsible for overall regional planning, funding and health-care integration. The job of co-ordinating face-to-face services, which now falls to CCAC staffers, may be moved to primary care agencies, such as hospitals or community health clinics led by doctors or nurse practitioners. The goal is to save more than $200 million by eliminating the bureaucracy-heavy CCACs, with their high-paid executives, and directing the savings to front-line services.

More than 700,000 Ontario residents receive care annually at home or in community settings. The province spends $2.5 billion a year on home and community care, about 4 per cent of its total health budget. Despite overwhelming evidence that the system is in dire need of reform, Hoskins seems reluctant to move ahead with any speed. Two months ago his office cancelled a private lock-up for home-care stakeholders at which they were to discuss a "white paper" on reforms. Hoskins also scrapped plans for a special home-care task force on the grounds it would be viewed as just another stalling tactic. Still, Hoskins is indeed moving, albeit slowly.

On Nov. 20, he spoke privately with the board chairs and chief executive officers of the 14 CCACs about the coming changes. On Nov. 30, Bob Bell, the deputy health minister, met with the same CCAC bosses and while he didn't share any "concrete plans," he did suggest health ministry officials will consult with CCACs and other agencies about the proposed changes "in the new year." And on Dec. 1, Hoskins wrote to the CCAC bosses to explain that his ministry has every intention of "working together with CCACs to build a health care system that truly responds to the needs of patients and their families." Again, no specifics were mentioned. Clearly, Hoskins is dealing with a health-care establishment that is reluctant to change. That includes the CCACs, LHINs, doctors and his own bureaucrats.

LHIN officials, for example, don't want to be in charge of direct delivery of care. They have few staffers who actually know how to run a big health system on a day-to-day basis. At the same time, the LHINs have their own troubles, as Lysyk noted in her report. She said their "marching orders are not clear enough" and performance gaps are widening, especially on wait times. In the weeks ahead, Hoskins must address whether the LHINs are ready to assume greater duties, whether they should be in the health-care delivery sector at all and how to achieve better integration of hospitals, public health, primary care and home-care agencies. Also, he should look at whether all - not just some - home-care delivery should be left to private and non-profit service providers. Hoskins and his bureaucrats may be delaying the reform push until they develop "the perfect plan."

But Hoskins, who has shown true vision in this initiative, should view the document as the starting point - not the end point - for wholesale reforms that cut out an entire layer of costly bureaucracy and that improve the delivery of services that patients need and deserve. Everyone in the health-care sector is primed and ready to act, although not eagerly in all cases. Just as important is the fact that more delays and more wasted tax dollars won't fix the broken system. So it's time for Hoskins to end the needless holdups and move swiftly and boldly on behalf of the people who really matter - Ontario patients. Bob Hepburn's column appears Sunday. bhepburn@thestar.ca

Ontario Health Minister Eric Hoskins may be delaying action until his team develops "the perfect plan" for home-care delivery, Bob Hepburn writes. • Chris Young/THE CANADIAN PRESS file photo

Ms. Carter's efforts are just part of a broad effort of Canadians to welcome refugees from Syria. But her work also highlights the ad hoc preparation that is taking place while the federal government scrambles to meet its commitment to bring 25,000 refugees to Canada in the next three months. The Immigrant Services Society of B.C. expects about 400 refugees, half government assisted and half privately sponsored, to resettle in the province by the end of December. Governmentassisted refugees will be placed in the lower mainland, but privately sponsored refugees will head to the communities where their sponsors are based - Victoria, Kelowna, Duncan and Prince George are preparing to greet refugee families before the end of the year.

No more than 20 refugees will likely arrive in the region where Ms. Carter and her team of volunteer professionals are ready to help. Other communities may not be as well served - there is an element of good fortune that the Victoria region happens to have an experienced volunteer corp of therapists at the ready. Ms. Carter just spent four years with the Centre for Victims of Torture in Jordan, where she worked with hundreds of Syrian refugees. Before that, she specialized in trauma support with Medecins sans frontieres (Doctors Without Borders). From that experience, she knows the counsellors themselves will need ongoing support to deal with the topics they'll be processing. "Many of these refugees have gone through incredible trauma," she said. "The stories are very difficult to hear, even for experienced counsellors."

And, after 25 years working in child and mental-health services in Victoria, she knows the system is already strained and would not be able to cope with the urgent needs of the new arrivals. "Mental-health services for adults and children are very, very sparse. Often Canadian children have to wait for months to get into our mental-health system. I'm very concerned that the refugees, when they come to Canada, most of them of have a lot of PTSD symptoms and they are going to need assistance and there was really nothing set up."

Victoria Mayor Lisa Helps is coordinating efforts among immigration support groups, the region's school districts, postsecondary institutions and other levels of government to welcome an unknown number of refugees in the next three months to southern Vancouver Island. "We are rolling out the welcome wagon, recognizing that it looks different for refugees from a war zone," she said in an interview. The biggest challenge, she said, will be finding a place for the new families to live: Victoria has one of the lowest vacancy rates for rental housing in the province, and low-rent housing is particularly squeezed.

"We want to provide a welcoming new home. It will take a heroic effort." These stories are emerging across the country - Canadians pushing aside security fears and making the near-impossible happen.

a safe seniors' strategy, a national prescription drug program, developing a health human resources plan, and committing to a strong publicly-funded health care system.

OMA President Dr. Mike Toth says the province owes doctors a “fair, reasonable negotiation done in good faith.” This ought to include an impartial, binding process for resolving an impasse between the parties, he adds. “There’s a power imbalance if the government can go through a series of negotiations and still have the right to unilateral action without any recourse.” OMA wants negotiations to go through a form of mediation–arbitration that would give a neutral third party the power to issue a binding decision in cases where the province and doctors can’t agree. Failing that, “we’re also looking at our legal options,” Toth says.

Eight of the provinces and territories currently have a binding dispute resolution mechanism, although they may not often use it, he explains. The Canadian Medical Association also gave its support to OMA’s request for mediation-arbitration at its August General Council meeting in Halifax. Normally, the national doctors’ association doesn’t get involved in provincial pay disputes, but in this case there could be national implications. According to Steven Barrett, a constitutional lawyer with Sack Goldblatt Mitchell in Toronto, if physicians feel there isn’t a fair process for determining their compensation within Medicare, they may be more willing to advocate for their right to practise and bill outside the public system.

Negotiations between doctors and the Ontario government have stalled since January, after the OMA rejected a proposal to cap growth in the physician services budget at 1.25%. Ontario ended up imposing the cap anyway, despite the fact that its own estimates peg the current rate of growth in demand for medical services at 2.7%. This means doctors won’t be reimbursed if patient demand for their services exceeds the limits of the public purse.

The province hasn’t given the OMA current data on health care use, but it’s “probably a safe bet to say it’s running over budget,” says Toth. Stephen Skyvington, a former manager of government relations for the OMA, recently reported that Ontario is withholding the data to prevent doctors from slowing their work in protest of pending claw backs.

David Jensen, a spokesperson for the Ministry of Health and Long-term Care, denies that this is the case. “The ministry continues to share data with the OMA per our data sharing agreement.” Jensen neither confirmed nor denied reports that spending on physician services is running 10%–20% over budget. In theory, doctors can protest pay cuts through work slowdowns and strikes, but it’s often not politically or ethically feasible because of the essential nature of their services. Nevertheless, “we’re obviously looking at all of our options right now,” says Toth.

The OMA successfully brought Ontario back to the bargaining table in 2012 by launching a constitutional challenge to unilateral cuts imposed by the government of the day. Ultimately the parties resolved their differences out of court, producing fee agreements for fiscal years 2012/13 and 2013/14. At the same time, the OMA agreed to the current negotiating framework, in which the government may act unilaterally if an impasse remains after receiving help from a facilitator and advice from a conciliator. “During the latest round of negotiations, this process was followed,” explains Jensen, for the ministry. A binding dispute resolution process “wasn’t on the table” in 2012, says Toth. “We couldn’t get to it at that time but we think we can get to it now.”

Hoskins said he wants to follow through on Winkler's recommendation to create a task force to make recommendations for improving and funding physician services. "One of the things Winkler spoke to was putting together a team from the OMA and from the ministry and other stakeholders, to really, in a serious way for quite frankly the first time, look at the issue of physician compensation and the delivery of health services by physicians," Hoskins said. "(It would address) how they can and should be best compensated, how to create a sustainable way of doing that, how to frame it within the reforms that are taking place in the health-care system. There's a lot we can do together," he added.

The OMA has so far issued no public response. The organization's board of directors is gathering on Wednesday and plans to discuss the Hoskins' meeting. In an email update sent to doctors on Monday, OMA president Dr. Mike Toth said board members plan to discuss next steps, including possible legal action. The update hints that doctors may be preparing to take some sort of job action. Toth wrote that 200 physician leaders met on Sunday and held a "brainstorming exercise designed to test and confirm innovative and impactful actions that members might undertake in various clinical settings and geographic areas across the province."

A new initiative by Canadian company CognisantMD hopes to reduce those waiting times. It has created a Syrian Refugee Medical Intake Tool, providing newcomers with a way to complete a full patient history and mental-health screening in their native tongue.

But McKenna argued nurses in the long-term sector have gone into rooms where a homicide has occurred, and those in emergency rooms constantly deal with victims of violence and horrible accidents.

"You shouldn't exclude particular workers because they might not be the first one to step their foot into a vehicle accident setting," she said. The legislation would mean first responders could access Workplace Safety and Insurance Board (WSIB) benefits far more easily than they can now.

The presumptive legislation, if it passes third reading as expected, is slated to be proclaimed into law Wednesday. It had been long sought and has now been widely lauded by first responders.

In a statement issued on behalf of 8,000 Ontario paramedics, the Canadian Union of Public Employees (CUPE) said the bill will help lessen the stigma associated with PTSD and help first responders get treatment "before it's too late."

"Research shows that because of frequent exposure to traumatic situations, paramedics and other first responders are at least twice as likely to suffer PTSD than the general population," the CUPE statement says.

Craig MacBride, spokesman for Labour Minister Kevin Flynn, said the government is committed to workplace safety for nurses, creating a leadership table on violence in health care and also amending the Occupational Health and Safety Act to help prevent workplace violence and harassment.

It's also important to remember that nurses, like all Ontario workers, are covered for PTSD through the WSIB. Bill 163 simply creates a more responsive process for those who are most likely to face traumatic experiences on a regular basis," MacBride said.