Unconventional Candour

by George Smitherman

  CHAPTER FOUR

  Health

  On October 23, 2013, I was sworn in as minister of health in the first Liberal government in Ontario for thirteen years. As I said at the beginning of this book, it was heady territory for the son of a trucker from Etobicoke with no post-secondary degree and no experience in cabinet. But I didn’t arrive at the Ministry of Health with a blank slate. Far from it. I had a detailed mandate in the form of the Liberal platform. I had my values informed by the fight for the Wellesley Hospital. And I had deep exposure through Carolyn Acker to the Regent Park Community Health Centre’s model, which brilliantly proclaims that no community is going to prosper so long as all the best jobs in the community are going to people from outside.

  Luckily for me, the Liberal platform relied heavily on the 2002 report of the federally appointed Royal Commission on the Future of Health Care in Canada. I had accompanied Premier McGuinty when he made a presentation to the commission, chaired by former Saskatchewan premier Roy Romanow. Both the party platform and the commission report contained full-throated endorsements of a single-tier, universally accessible, publicly funded health care system. The goal was to modernize medicare and address its glaring shortcomings without resorting to privatization or a two-tier format as panaceas for the access and quality citizens desired. The platform included promises to shorten wait times for several critical areas — cardiac care, cancer treatment, diagnostics, and joint replacements. Shortening wait times had been a key Romanow recommendation. We also promised to establish “family health teams” with interdisciplinary groupings of doctors and other health professionals collaborating to deliver enhanced care and better access hours for patients. And we pledged to expand home care, invest in mental health, and increase the supply of nurses and doctors. The doctor shortage was to be addressed, in part, by removing barriers to foreign-trained physicians and so put to rest those nagging stories about doctors driving taxis.

  October 2003, the first McGuinty cabinet swearing-in. Full deer-in-headlights in effect, according to the look on my face (top row, third from left).

  We managed to do most of this, notwithstanding the budgetary constraints on us. The McGuinty government inherited a massive $5.6 billion deficit from the previous Conservative regime (under Premier Ernie Eves) — a shortfall that had been covered up in the budget immediately preceding the election. And that $5.6 billion was a low-ball figure, for it overlooked the $1 billion in accumulated hospital “working capital deficits,” which were off the government’s books but guaranteed by the province.

  So I approached David MacNaughton, McGuinty’s principal secretary (and now Canada’s ambassador to the United States). I knew MacNaughton well and enjoyed working with him. We had a chat about the hospital deficits outside the Legislative Building. I recall him turning back over his shoulder as he walked away and saying, “We will find a way.” But I think he and I both knew that it was going to be very tough. I do not know whether he shared my sense of lost opportunity, but those hospital deficits loomed large every one of the 1,702 days I served as health minister. But if every big issue at the health ministry were labelled a crisis, that would not engender public confidence, and restoring confidence in the system was at the heart of my mission.

  People use the expression “drinking from a fire hose” to describe the information overload involved in taking on a new challenge. That may have been an apt description for ministers in other portfolios. At Health, where spending is measured in billions, not hundreds of millions, I was drinking from a river with a lot of powerful tributaries. The flow of information was remarkable. Just for example, nearly four hundred thousand pieces of correspondence get addressed to the minister annually.

  But before grappling with substantive issues, I faced another challenge: filling some thirty-odd positions on the minister’s staff. As head of the largest operating government department in Canada with eight thousand direct employees, four hundred thousand indirect employees, a $30 billion budget (at that time), and about half of all the government appointments to agencies, boards, commissions, and regulatory bodies, Ontario’s minister of health has one of the largest political staffs in the country.

  Within one minute of stepping off the elevator and before I even set foot in my own office, I looked down the long hallway of empty offices and got a sinking feeling. I called over to someone in the Premier’s Office and said: “If you have any adults around, please send them over.” Lo and behold, soon afterward I was connected to Charles Beer, then sitting on a dock and drinking a beer. Beer was a veteran of the provincial Liberal Party. He had been minister of community and social services in the Peterson government, and he had run for the party leadership in 1992 (losing out to Lyn McLeod). Besides being experienced, he had the advantage of being widely liked and wise. A phone call that started out as a link to an informal adviser progressed quickly and I wisely named him my executive assistant. He was an enormous help to me because he was familiar with the rhythm of government as well as being a calming presence. He helped me survive in my early days in the ministry.

  Working with Hugh O’Neil had taught me that the number-one key to a minister’s survival is effective management of relations with the government caucus. For caucus liaison, I chose Scott Lovell, who had been my campaign manager in Toronto Centre and my executive assistant in opposition. Lovell had been trained in attending to local matters by his mother, Ruth, then mayor of Owen Sound.

  He became known as the go-to guy for MPPs of all parties. (Partisan as we were, our effort to aid MPPs was not.) They came to know that, if they wanted to talk to me about an issue or a scheduling matter, they had best start with Lovell. We had great fun keeping the map in Scott’s office up to date as we celebrated every new hospital visit or other event, such as a fundraiser, that took us to a riding that was new to us.

  As director of policy, I chose my long-time friend Jason Grier, who had been director of public affairs at Wellesley hospital and then McGuinty’s chief health policy adviser in opposition. At Health, he and I assembled the finest starting line of political policy advisers I have ever seen. Proof positive is how their careers evolved after they left my office: Grier became a noted health strategist at Santis, a boutique health consultancy where he works with Dan Carbin and Janine Hopkins; Ali Samian is a global pharma executive; Rita McGrath continues to run health care systems in the Middle East; and Ken Chan was recently named an assistant deputy minister in the Ontario government.

  Grier had written most of the health sections in the Liberal platform. In effect, he was my living mandate letter. There were also a couple of notable health policy experts in the Premier’s Office with whom we worked closely and co-operatively: Karli Farrow and Jamison Steeve, each of whom later became my chief of staff. My office sought to be in alignment with them on the issues of the day, because in a Westminster-style government progress is made much easier when one enjoys the support of the so-called centre (the Premier’s Office).

  Changes were also afoot among the senior civil servants in the health ministry even before I arrived. For, in the transition period, the premier-elect comes into contact with the senior bureaucrats BEFORE the not-yet-appointed ministers see them. And suffice it to say that premier-elect Dalton McGuinty did not see eye-to-eye with the deputy minister of health, Phil Hassen, who had just been recruited from a Vancouver hospital by the previous Conservative government. So McGuinty fired Hassen and replaced him with an acting deputy, Marguerite Rappolt. She was a career bureaucrat who was very skilled at holding the fort and had a tremendous institutional memory. Fortunately for me, another Conservative recruit from British Columbia, Hugh MacLeod, was already at the ministry and was named associate deputy minister. His agile mind and Rappolt’s steady-as-she-goes approach made for good progress.

  Rappolt was there only on an acting basis, however. To replace her, Tony Dean, the cabinet secretary (the province’s chief bureaucrat, and one of the best public servants I have ever known) allowed me to int
erview the final two candidates for the position: Ron Sapsford, who had worked for the Tory-appointed Health Services Restructuring Commission and then became COO at Hamilton Health Sciences, and Kevin Smith, CEO of St. Joseph’s Healthcare, also in Hamilton. I liked them both and felt good chemistry with them. When Sapsford emerged as my deputy, the health community was very pleased. He had a rich history in Ontario health care, beginning at the District Health Council in Owen Sound, and was well placed to help lead the transformation of the ministry.

  While I understood how important the bureaucrats were, my first instinct in my earliest days was to reach out beyond them to key players in the health sector on my own. (This established a pattern that I would carry on throughout my tenure.) I took to the road to meet doctors and nurses. Nearly immediately, I drove to an outdated strip mall in Scarborough to see Dr. Larry Erlick, a family physician who was then president of the Ontario Medical Association. I made sure he knew that I had my own priorities. In particular, we discussed the always-sensitive issue of compensation adjustments among doctors influenced by new technology. Erlick gave me a hint at some of his early priorities, including compensation for general surgeons and psychiatrists.

  Another early contact was with Doris Grinspun, executive director (later CEO) of the Registered Nurses Association of Ontario. She took me on a tour of Mount Sinai and North York general hospitals. The theme of our visit was unsung heroes. This was the first of a multitude of steps I took to acknowledge the role of nursing and, especially, the risks. That day at North York General, I paid my respects at the memorial to Nelia Laroza, the nurse who died there during the 2003 SARS epidemic. (Later in my time as minister, I was faced with a recommendation that there be different levels of protective masks for different health care professionals in case of a pandemic. I overruled the ministry advisers and insisted on the highest protection standard for all who were risking their lives for all of us, despite the higher cost.)

  SARS was still fresh in everyone’s mind when I became minister and had a big impact — financial, emotional, and regulatory — on my early days in office. The Conservatives had appointed Justice Archie Campbell to inquire into the province’s response to the crisis, and I inherited his excellent report. His recommendations became my marching orders for fixing the public health system in Ontario, which had shockingly been allowed to deteriorate under the Tories. I didn’t need Campbell to tell me everything that needed doing, however.

  One of my first actions was to remove Dr. Colin D’Cunha, the province’s chief medical officer of health. (The office handles communicable disease management, health promotion, chronic disease, injury prevention, and emergency preparedness.) D’Cunha had presided over the province’s response to the SARS outbreak, which killed forty-four Ontarians. He was, to be frank, not a confidence-inspiring individual. A blue-ribbon panel blamed the crisis, in part, on the infighting between the federal government and D’Cunha’s office. “The lack of collaboration between the federal and provincial governments [during the SARS outbreak] was an international embarrassment,” said David Naylor, the University of Toronto’s dean of medicine and head of the panel. So D’Cunha was encouraged to pursue new challenges, and I replaced him with Dr. Sheela Basrur. Looking back, I think it was the single most impactful thing I did as minister of health.

  Basrur was Toronto’s medical officer of health during SARS and was hailed for her work in handling the crisis. Especially evident were her clear-headed communication skills. She had also distinguished herself in other areas, including implementing a city-wide ban on public smoking and requiring restaurants to post the results of health inspections of their premises.

  I had to sell Basrur on making the switch from the city to the province. Rather than go through the usual channels, I contacted her directly and told her we were willing to pour resources into public health (including a huge upload of costs from municipalities to the province) to put wind back in the sails of the people in the sector, who had felt like outcasts under Mike Harris. What astonished me was that she was surprised to be asked, which tells you a lot about her lack of ego. She was leading the largest public health organization in the province, and she was a great communicator — a key skill in the public health field. In other words, she was the obvious choice. “You have to do this for the sake of the province,” I told her. “You’re a hard man to say no to,” she replied. At her city hall exit party, Mayor David Miller griped to me: “Thanks a lot for stealing my prize talent.” I retorted: “With all due respect, your worship, her talents are needed for a higher purpose.”

  Basrur and I did some great work together as we rebuilt the capacity of the public health sector across the province. Among other things, we created the regulatory environment for food carts and trucks to expand their offerings beyond their traditional fare of hot dogs and sausages. And we introduced the Smoke-Free Ontario Act, which replaced a ragtag collection of municipal bylaws with one strong ban on smoking in public places across the whole province. Another feature of the act that I am proud of was requiring hidden displays for cigarettes in stores.

  The legislation prompted an internal debate as some argued that the government-owned casinos should be exempt from the smoking ban. Apparently the incidence of smoking is higher among gamblers than in the general public, and the casinos foresaw a rapid decline in attendance — and, by extension, government revenues — if smoking was banned on their premises. But, with Premier McGuinty’s support, we stuck to our guns. “You can’t ask people to support a government policy if the government is exempting itself,” said McGuinty.

  (An aside: Except for a bad stint in Grade 3, I have not been a smoker myself, although between my mother, grandmother, and many nights in smoky gay bars — hello Eartha Kitt, Key West, 1993 New Year’s! — I have consumed a lot of second-hand smoke. During one rare evening session of the Legislature, Conservative MPP John O’Toole accused me of being a smoker. He said he and I had smoked together by the Legislative Building’s east door. I thought he was mistaking me for another cabinet minister from Toronto and asked him to correct the record. When he refused, I called him a liar and got thrown out of the Legislature for using unparliamentary language. It was worth it to make a point.)

  Basrur and I were not always in agreement, and those moments were especially fun. By necessity, there is a streak of independence in the public health sector. One dispute was over implementation of a public health regulation requiring raw fish to be frozen before it was served. Sushi chefs and consumers were outraged, and we quickly backed down. I remember her at my office door with a fresh regulation in hand. “Sorry, boss,” she said. Luckily, we moved fast enough that most people don’t remember the frozen sushi “scandal.”

  Another dust-up involved the growing determination on the part of public health officials to make sure farmers’ markets and other outdoor food-serving events were safe for consumers. Overzealous prosecution led to a real backlash. It was brought to a head when public health officials poured bleach on egg salad sandwiches to prevent their sale at an outdoor event in Windsor. The sandwiches, made by volunteers, were to be sold in support of an important Windsor heritage property. Notwithstanding the risk of food poisoning from egg salad left in the hot sun, the bleach attack sparked a reaction. That led to a new regulatory framework that has contributed to a wonderful expansion of the popularity of farmers’ markets. Heritage advocate that I am, I sent a personal cheque to the organizers in Windsor to let them know that I hadn’t missed the story.

  Overall, Basrur and I worked well as a team and accomplished a lot. Unfortunately, she had to step down for health reasons in December 2006, less than two years into her job. We named the Public Health Agency after her, and the naming ceremony at MaRS (the Toronto Discovery District project) was among the most touching I have ever experienced. I was lucky to get to know Sheela’s daughter, sister, and parents, who were so welcoming to me. When she succumbed to cancer in 2008, a friend of Sheela’s lashed out at me out of sorrow
and said Sheela died because I worked her too hard. Maybe, but I don’t think she would have had it any other way. Nevertheless, the comment continues to sting.

  * * *

  One of my first pieces of legislative business as minister was to introduce the Commitment to the Future of Medicare Act, a promise from the campaign platform binding the government to “universal, public medicare.” Somewhat symbolic, at one point it was under consideration to be the first bill introduced by the new government. (It lost out to a bill cancelling the private-school tax credit and increasing corporate taxes.) In connection with my bill, a departmental briefing was scheduled. When the bureaucrats assembled, I was surprised to see one Thomas O’Shaughnessy, a senior policy adviser in the ministry, in the lead. Ironically, he had taken a leave of absence to be the campaign manager for John Adams, my Conservative opponent in the provincial election just concluded, an election during which O’Shaughnessy had heckled me at an all-candidates meeting. Luckily for him, I don’t hold grudges.

  It was one of many examples where I saw no threat in having people of different political stripes working for me. Another was Gail Paech, assistant deputy minister of health under me. In 1999, she had lost the Conservative nomination in my riding to Durhane Wong-Rieger by one vote. (Yes, there were accusations of ballot-stuffing.) The deputy minister’s office also had two key staffers who supported me and my team so well. One, Lana Sheinbaum, I had known as a Peterson staffer, while the other, David Sachow, had previously served on Tony Clement’s staff. Fact is, working on the political side made these folks very aware and perhaps sympathetic to the challenges facing a politician. Accordingly, they served me loyally and with great effect.