Ontario Pre-budget 2014: Finding the Right Balance
Good afternoon. My name is Doris Grinspun and I am the CEO of the Registered Nurses’ Association of Ontario (RNAO). With me today is our senior economist, Kim Jarvi. RNAO is the professional association for registered nurses who practise in all roles and sectors in Ontario. Our mandate is to advocate for healthy public policy and for the role of registered nurses in enhancing the health of Ontarians. RNs know from personal experience the impact that budgets have on health, health care, and on the nursing profession; and we appreciate this opportunity to share our views on the 2014 Budget. We have been asking for a balanced approach to budgets for the past few years, and we are cautiously optimistic that this year the government will move beyond austerity measures, as it suggested in its fall economic statement.
When we speak of a balanced approach, of course we are talking about a rough balance between expenditures and revenue over the business cycle. We need to deal with the fiscal deficit seriously, and that means recognizing it for what it is: a constraint – a very manageable constraint – and one that must be balanced against growing social, health, environmental and infrastructure deficits. For example, we are encouraged that the government is looking at ways to raise revenue to pay for the huge transit infrastructure deficit across the province. Failure to deal with this deficit costs billions of dollars per year in the Greater Toronto region alone. The sharp spike in unemployment in Ontario to 7.9 percent reminds us that we are a long way from recovery from the 2008 recession and the low incomes associated with it. This brings fresh urgency to the call for a balanced approach, a balance that asks:
- What expenditures are necessary to strengthen an inclusive, healthy, and sustainable Ontario?
- How do we pay for those services?
- How much debt is reasonable to deliver the necessary investments?
- How and when we reduce the debt and deficit?
Our read is that there is significant unused capacity in the economy now, and considerable need for government to address the non-fiscal deficits we just mentioned, through a combination of reallocation of resources, new revenue and judicious borrowing at low interest rates.
Our recommendations begin with nursing care.
RNs provide the bulk of direct care by health professionals in Ontario. RNs have had a roller coaster ride at budget time. Budget-cutting in the 1990s saw thousands of layoffs. This triggered a vicious cycle of RNs leaving the province, soaring workloads and burnout that hurt patients, RNs and health organizations. It took a concerted effort by successive governments to reverse the downward spiral, through the creation of thousands of nursing positions. However, the 2008 recession led to austerity measures that fell particularly hard on RNs, with layoffs and reduced access to RN services. Today, Ontario has the second worst RN-to population-ratio in the country, and needs almost 17,600 more RNs to catch up with the rest of the country. We have five recommendations related to Nursing Human Resources:
Nursing Human Resources
Recommendation 1. Narrow the gap of about 17,600 RN positions by immediately focussing attention on RN recruitment and retention.
A place to start restoring RN positions is in long-term care. Thus,
Recommendation 2 is to protect the safety of our seniors and to ensure their timely access to quality care, phase in new minimum staffing standards in long-term care, starting with a minimum of one Nurse Practitioner per 120 residents.
Recommendation 3 focuses on ensuring 70 per cent full time employment for all nurses, so that patients have continuity in their care and care provider. We have seen huge progress in this area but the job isn’t done yet. In 1998, less than 50 percent of RNs had full-time employment, which is terrible for continuity of care and terrible for the profession. The government committed to 70 per cent full-time employment for RNs, and by 2012, had raised the level to 68.6 per cent. Unfortunately, 2013 saw the loss of many full-time positions and the ratio dropped to 66.8 per cent. We MUST get back on track and achieve the targeted 70 per cent full time employment for all nurses in Ontario.
Recommendation 4 deals with maximizing and expanding the role of RNs to deliver a broader range of care, such as ordering lab tests and prescribing medications to improve access to care for Ontarians and optimize outcomes
Recommendation 5. Secure fair and competitive wages for nurses and nurse practitioners working in all sectors of health care. RNs face substantially lower compensation in primary care and home care, while Ontario NPs receive substantially lower compensation than NPs in jurisdictions like Alberta.
Nurses in the Health System
RNs are highly motivated and highly educated, and they want to do more to expedite high-quality and cost effective access to health care. A health-care system anchored in primary care where each interdisciplinary team member is enabled to work to full scope of practice, will bring health care closer to people, and make best use of investments made in the health-care system. To ensure coordination between the various elements of our health system, we must also enhance system integration and decrease duplication. To achieve this, RNAO has four recommendations:
Recommendation 1. Support Local Health Integration Networks (LHIN) to achieve regional health system planning, integration and accountability for all health sectors, using an evidence-based and person-centred approach rooted within a population health, primary health-care framework.
Recommendation 2. Commit to providing all Ontarians with access to integrated inter-professional primary care by 2020, in NP-led clinics (NPLCs), community care access centres (CHCs), Aboriginal Health Access Centres (AHACs) and family health teams (FHTs), and fund them to work to full capacity.
Recommendation 3. Improve coordination and person-centred navigation across our complex system by partnering with patients to co-ordinate their care through primary care.
Recommendation 4. Transition the 3,500 Case Managers and Care Coordinators from Community Care Access Centres into primary care. Do so through a carefully crafted labour management strategy that retains their salary and benefits.
Social Determinants of Health
There is a strong and well-established correlation between income and health. Nurses know this firsthand from their practice. Poor people live in less healthy circumstances and face greater stresses. As a result, they suffer higher rates of ill-health and early onset of chronic disease, and they die much earlier. Furthermore, the loss of human potential is incalculable. We are all the poorer for this needless suffering.
Whatever our economic challenges, there is no excuse to tolerate the high levels of poverty, particularly in First Nations.
We know public policy can make a huge difference in people’s day-to-day lives and improve health outcomes. Ontario has taken some steps with its first Poverty Reduction Strategy released in December 2008. Early investments in increasing the Ontario Child Benefit helped reduce the child poverty rate from 15.2 per cent to 13.8 per cent in 2011despite the global economic recession. However, we have a long way to go just to get back to the 9.9 per cent child poverty rate of 1989.
In May 2009, all three parties voted unanimously to pass Ontario’s Poverty Reduction Act, which commits successive governments to remain focused on the fight against poverty. Ontario raised the minimum wage in increments from $6.85 to $10.25, which was significant to the working poor, but this progressive policy ended in 2010. RNAO supports the community campaign to increase the minimum wage to $14, which would be 10 per cent above the poverty line. It is crucial that we all work together to eliminate poverty so that all Ontarians can live in health and dignity. RNs offer four recommendations:
Recommendation 1. Immediately increase the minimum wage to $14, and automatically index it to the rate of inflation in order to bring workers above the Low Income Measure of poverty.
Recommendation 2. Improve access to affordable housing and stimulate job creation in the process.
Recommendation 3. Transform the social assistance system to reflect the actual cost of living.
Our full prebudget submission has full details on our social assistance and housing recommendations.
Environmental Determinants of Health
Nurses know that the environment is another determinant of health. Morbidity and mortality are related to exposures to environmental contaminants. Ontario has taken strong action to remove one of the worst offenders: coal-fired power plants. This is a very significant step, making Ontario a world leader. Ontario has also led the way in banning the non-essential use of pesticides. Spurred by revelations that Ontario was one of the top emitters of toxics in North America, the province has made some progress on the right- to-know about toxics with its Toxics Reduction Act. We hope that Ontario will also move on costly vehicle pollution and urban gridlock by making significant investments in transit infrastructure.
Recommendation 1. Set ambitious toxics reduction targets. Ensure people have the right-to-know about the existence of toxics in the environment, in their homes, in their workplaces, and in consumer products.
Recommendation 2. Minimize the energy footprint by: focusing first on conservation and energy efficiency, relying minimally on existing coal plants until they are closed, increasing reliance on renewable energy, and strategically using natural gas and hydroelectricity imports from Quebec to meet any energy shortfall.
Recommendation 3. Create new dedicated revenue sources to pay for a substantial expansion of transit and active transportation.
Our publicly-insured health-care system faces increasing pressures, particularly at times like this when budgets are tight and when the system is in transition from a focus on acute care, which is covered by the Canada Health Act (CHA), to a more community-based system that is not fully covered under the act. Added to this is federal cutting of provincial health transfers and indications that the federal government has no intention of renewing the 2004 Health Accord that traded federal health transfers for performance undertakings. When public money is scarce, private money may show up, but at an enormous human and financial risk. We are aware of medical tourists jumping the queue in Ontario and have urged Minister Matthews to prohibit such activities as did her Quebec counterpart. RNAO urges:
Recommendation 1. Rejecting efforts to commercialize or privatize health-care delivery. Place a moratorium on new P3 negotiations and contracts. Prohibit Medical Tourism, and do not allow Canadians or foreigners to buy their way to the front of a queue for insured health-care services.
Recommendation 2. Working with the other provinces and territories to bring the federal government back to the table to negotiate a 2014 Health Accord.
Recommendation 3. Expanding our publicly funded, not-for-profit health-care system to all medically necessary areas, starting with universal home care, universal pharmacare and dental care for people living with low income.
Recommendation 4. Focusing on well-researched and demonstrated policies and evidence-based clinical practices to optimize the health of people, families, communities, and our health system.
Recommendation 5. Given the federal threat to close the door on supervised injection services, we urge Premier Wynne to demonstrate leadership and immediately fund services in Toronto and Ottawa.
Many of the measures we propose above will save money in the short or long run. However, it will unquestionably cost a significant amount of money to pay for the services needed in a healthy society. It is imperative that we find ways for the government to pay for them. And we have recommendations to do just that.
Recommendation 1. Ensure the fiscal capacity to deliver all essential health, health care, social, and environmental services by building a more progressive tax system.
Recommendation 2. Increase revenue sources that encourage environmental and societal responsibility. Begin by phasing in environmental levies, such as a carbon tax, to help pay for the damage polluters cause and to support the social programs and services most needed by at-risk populations.
Recommendation 3. Work with the federal government to research the scope of tax evasion losses, and then put in resources to recover the lost revenues.
We wish to thank the Standing Committee for giving us this opportunity to present the views of the registered nurse profession on the budget.