The April cuts had left a $8.5-million shortfall which was growing by $300,000 a week. The second round will reduce that gap to $900,000, likely to grow to more than $1 million before the latest changes are in place, said Toni Adey, a spokesperson.

The job cuts and money-saving strategies don't include a proposal to merge TSH's two Maternal Newborn programs into a single program at the Birchmount campus, which consultants said would save the hospital up to $5 million a year, or another plan to do all complex surgery at the General campus and all day surgery at the Birchmount.

But it falls short of the oft-repeated "five-day home-care guarantee" Horwath has been pushing since shortly after Premier Kathleen Wynne took over from Dalton McGuinty.

"These are going to be very, very hard cuts to the hospital, but we have to do them to balance our books," said Dr. Robert Ting, president of the Scarborough Hospital's medical staff association. On Wednesday afternoon, staff at the hospital attended town hall meetings where they were told more cuts were coming. The hospital is looking at closing two operating rooms, a surgical wing with up to 20 beds and several outpatient clinics, including a rheumatology clinic for patients with arthritis. Earlier in the year, staff were told 98 positions were being eliminated.

Ontario

"The government's attempt to downplay their health-care cuts is demonstrably false. Hospital beds are being closed in significant numbers and these services are not being replaced in local communities," Mehra said.

But some insiders say the cuts are having a big impact. "People will notice for elective things. Things that are super-urgent will still get done, but non-urgent things like hernia repairs or gallbladder (surgeries) will definitely get pushed back," Ting said.

Matthews said the shift from hospital to community care, though bumpy, demonstrates the success of the transformation of Ontario's health system. "This is a deliberate strategy," she said.

The proposed changes were prompted by the recent discovery of under-dosing of chemotherapy drugs supplied by an independent company to four hospitals in Ontario and one hospital in New Brunswick.

Community Care Access Centres will receive $33 million in additional funding to reduce the waitlist for in-home physiotherapy services, which will help to keep more seniors and eligible patients healthy and at home longer. Up to 60,000 more people, mostly seniors, will receive physiotherapy in the comfort of their own homes, benefitting 150,000 people in total.

Over the coming months, the Ministry of Health and Long-term Care and the LHINs will engage physiotherapy providers and community partners interested in delivering these services in communities across Ontario.

Until now, a small number of for-profit companies have had almost exclusive control over the delivery of publicly-funded physiotherapy.

Horwath has an opening, however, to use the Mississauga mess as a teachable moment: to illustrate how the ideology of privatization trumps practicality.

It was the Liberal embrace of privatization in 2004 that drove the government to contract out any new power generation — from gas-fired plants, solar and wind — to the private sector, explicitly sidelining government-owned Ontario Power Generation.

Not in Mississauga, where the private sector ran out of time — and money. Eastern Power won the contract by bidding low for the project, but turned out to be a high-cost operator: Not only did it borrow money at 14 per cent (compounded quarterly), as the auditor noted incredulously, it demanded to be compensated for supposedly paying an administrative assistant at the rate of $110,000 a year. So much for efficiency. As for timing and diplomacy, Eastern Power failed to win over the local community, ultimately turning to the Ontario Municipal Board to overrule a zoning decision by Mississauga council.

But we have only ourselves to blame for falling under the spell of the privatization mantra years ago.

The real electricity scandal was our own wooly thinking — a highly charged blend of NIMBY myopia and privatization mania.

Manufacturing includes producing or selling a product by a third party, it said. The paper suggests that if there’s a question about whether the activity is manufacturing or compounding, it should be raised with federal or provincial bodies, who can then determine who’s responsible.

A 2009 policy paper by Health Canada cited “a need to develop a Canada-wide consistency in approach to ensure that drug compounding and manufacturing are each regulated by the appropriate authorities.”

The college oversees pharmacists, including those who may have worked independently for Marchese Hospital Solutions. Health Canada oversees drug manufacturing. But Marchese wasn’t considered a pharmacy or a drug manufacturer. The need for clarity about who is responsible for what is an issue Health Canada has been dealing with for more than a decade.

“In situations where the provincial/territorial regulatory authority decides that an activity does not fall within its jurisdiction, the activity is likely to be manufacturing and the parties involved must follow the federally regulated drug approval process for manufacturing drugs,” it said.

The services provided by Marchese to hospitals appear to be something that has been traditionally done within a hospital pharmacy, which would fall under provincial supervision, said Health Canada spokeswoman Leslie Meerburg. “This non-traditional business model takes a different approach,” she said in an email.

In the meantime, the college is stepping in to provide oversight of new compounding facilities like Marchese.

It was a jurisdictional grey area, with both the college and Health Canada unable to agree on who was responsible for the facility.

The crisis has also raised questions about whether the privatization of health care has gone too far. The bags containing the chemotherapy drugs were filled with too much saline, watering down the medication by as much as 20 per cent. Some patients received the drugs for as long as a year. It's a grave warning that privatization has to stop, said New Democrat health critic France Gelinas.

"As those new companies spring up all over to do for-profit services for hospitals, the government basically stayed asleep at the switch," she said.

"They never looked at who was picking up this work to make sure that the level of oversight, the level of quality assurance that we had before were being transferred over. The work got transferred, the oversight did not."

A pharmacy expert, Jake Thiessen, will review the province's cancer drug system, Matthews said. A working group that includes doctors, Cancer Care Ontario, Health Canada and others are also looking at the problem.

ealth Canada and the Ontario College of Pharmacists are working to close that ga

"This is a new way of doing business so we need to sort which activities are being done and then who has the overall oversight over them."

"My reaction was, 'I can't believe this happened to me'," Kaiman said from her dress shop in Woodstock, Ont. "They told me my chemo was watered down and that basically he thinks it may not affect me, but there are no guarantees."

Marchese has said the problem arose not from how the bags were prepared but in how they were administered at the hospitals.

We need answers and I am going to make sure the College of Pharmacists gets the tools they need."

“It does get a bit complex because under one roof with the operations, they actually have different areas that are doing different activities, and those different activities may actually be under different jurisdictions,” she said.

Marchese Hospital Solutions is technically not a pharmacy, which means it doesn’t fall under the oversight of the provincial government or the college.

However, the college is responsible for pharmacists and technicians, including those who may have been working independently for the company.

archese has a pharmacy in Hamilton, Ont., which was inspected by the college in January. Sharma said Health Canada had not visited any of Marchese’s businesses before the diluted drugs came to light, but paid a short visit after.

Outsourcing of medication preparation is a new trend and now’s the time to start looking at how it should be done in Canada, said Sylvia Hyland, chief operating officer of the Institute for Safe Medication Practices Canada.

“So it’s possible that we need to make sure that oversight and regulations are up to date.”

Marchese has said its products weren’t defective, and suggested that the problem wasn’t how the drugs were prepared but how they were administered at the hospitals.

McIntyre said these cuts are impacting nurses with five to 12 years experience. “We're losing a huge amount of experience and dismantling mental health,” she said Wednesday.

She said there's concern the hospital is using personal support workers to replace RPNs, which will affect inpatient quality of care.

Karen Bennett, vice-president of addictions, mental health and senior services at the North Bay Regional Health Centre, said union members weren't the only ones impacted by the recent wave of cutbacks.

She said several non-union positions were eliminated. When asked how many, Bennett said, she didn't have an exact number or how much was saved.

What's important is that the resulting discussions be driven by the facts - not anecdote, and not opinion.

Kitts, who is an anesthesiologist, said methods he practised a few decades ago, which required an anesthesiologist to be right beside the patient, are “primitive” compared with current technology, which measures carbon dioxide and oxygen levels. It would be possible, Kitts pointed out, for one anesthesiologist to supervise four or five operating rooms.

Meanwhile, most people can go into a drugstore and take their own blood pressure using a mechanized monitor. In a hospital, a nurse is required. Perhaps a less-skilled worker could do the job, leaving nurses free for more specialized tasks, said Kitts.

Kitts added that there also has to be an alternate level of care for patients who don’t need to be in an acute-care hospital but aren’t well enough to be at home.

Late in May, The Ottawa Hospital’s board of governors will be exploring ways to keep populations of patients with multiple health risks out of the hospital, said Kitts.

That will start by identifying these pockets of patients

Tory Leader Tim Hudak said it is the role of the government to protect it citizens, not throw up their hands and blame someone else for the chemo drug not being effective.

Working together to search out every opportunity to get patients home is working, he said.

At Tuesday's meeting, the HSN board officially approved a seniors' strategy for the hospital that will make it more senior-friendly -- based largely on recommendations of a province-wide report by Dr. Samir K. Sinha, director of geriatrics at Mount Sinai and the University Health Network Hospitals in Toronto.

Dr. Paul Saba, who is the president of the Coalition of Physicians for Social Justice, calls the cuts “totally unacceptable.”

Karl Rinas, 61, who was treated for a bleeding ulcer at a Leamington, Ont., hospital last February, says he ended up wiping down the bathroom himself after his complaints about the dried liquid waste he found on the floor and toilet seat failed to get a reaction, but he worried about older, less mobile patients.

Despite all her efforts, Martin says she has no doubt that the antibiotic-resistant superbug Clostridium difficile infection her mother contracted soon after surgery was related to the hospital's level of cleanliness.

"I know everybody nowadays has to work more with less, but to me, a hospital should be absolutely clean," she said.

Of the respondents who wrote into the fifth estate's survey about being harmed in hospital, most said the harm was a hospital-acquired infection such as MRSA and C. difficile.

Unlike in the food industry, there are no standardized inspections for cleanliness in hospitals.

A World Health Organization report that compared Canada's infection data with that of 12 other wealthy countries found that Canada had the second-highest prevalence (11.6 per cent) of hospital-acquired infections after New Zealand — much higher than that of Germany (3.6 per cent) or France (4.4 per cent).

Is outsourcing to blame?Those who work in hospitals have pointed to the increased outsourcing of housekeeping in recent years as one reason behind the decline in hospital cleanliness that patients and hospital workers have observed

"There's no question there's been an impact on the quality of cleaning, and you can see that throughout the years as various hospitals have struggled with very high-profile superbug outbreaks," said Margi Blamey, spokesperson for the Hospital Employees' Union (HEU), which represents 41,000 hospital cleaning and support staff in B.C.

But health authorities in other countries are moving away from private cleaning services. Four years ago, Scotland reversed its decision to allow outsourcing of cleaning and catering services because it felt private contractors were not doing a good enough job keeping the spread of infections in check.

Blamey says as long as housekeeping is done on a for-profit basis, employers will reduce the number of staff and cut corners on staff training and cleaning supplies.

The Canadian Nosocomial Infection Surveillance Program is the closest thing to a federal overview that Canada has, but it relies on voluntary reporting by only 54 hospitals in 10 provinces, most of them teaching facilities, which, according to infection control experts, generally have higher infection rates than other acute care hospitals because they tend to see more seriously ill patients.

Michael Gardam, who oversees infection prevention and control at the three hospitals that are part of Toronto's University Health Network, agrees that hospitals have fewer resources for housekeeping these days and have to concentrate cleaning on areas that are most likely to transmit bacteria — primarily the surfaces that multiple patients touch.

"I probably get more emails about dust bunnies in the stairwells than anything else in the hospital, and yet, we've done that for a reason. You're not going to catch anything from a stairwell, but you're going to catch it from your bed rails," Gardam said.

About two-thirds of hospital-acquired infections are preventable, Gardam said, but making a direct link between cleanliness and infection is not as straightforward as it might seem. Some hospital-acquired infections such as ventilator-associated pneumonia or central line-associated bloodstream infections have little to do with the hospital environment and can be controlled through proper protocols around equipment use. But a superbug like C. difficile is a lot trickier because it is hard to pinpoint its source.

Increasing cleaning staff on nights and weekends could also help. A typical medium-sized B.C. hospital that contracts out cleaning services has 24 cleaners by day but only four at night, says Blamey, and workers are often not backfilled when ill or on vacation.

"Bacteria don't care what time it is," said Gardam.

The infection expert says it doesn’t matter whether a private or public entity oversees cleaning; both have had problems with cleanliness. The bottom line is that hospitals generally undervalue the importance of cleaning staff, Gardam said.

"People don't really think of them as part of the team, but if you think about how infections are spread in hospitals, they're actually an incredibly important part of the team that goes far beyond just the cosmetic appearance of the room."