Ontario Pre-Budget Consultation 2017
My name is Kim Jarvi and I am the acting director of nursing and health policy with the Registered Nurses’ Association of Ontario (RNAO), the professional association representing registered nurses, nurse practitioners and nursing students in Ontario.
RNAO always presents at pre-budget hearings because the budget makes the most important decisions affecting health and the health system. That, in turn, affects the places where nurses work and their ability to positively influence health outcomes. Nurses urge the government to spend the right amount of money and to spend it in the right areas. Our experience tells us to take an upstream approach and invest in keeping people well, so we can avoid the much larger costs of dealing with consequences – the increased morbidity and mortality, human suffering, lost productivity, the costs of patching people up when they suffer illness and injury. If the government implemented a health-in-all-policies approach, we would not only have a healthier society, but also a healthier economy and a healthier budget balance.
The problem is the political process tends to focus budgets downstream on problems after they emerge.
For example, our submission highlights one investment that would save the system money while stopping avoidable diabetic foot amputations. Two-thousand Ontarians living with diabetes per year face lower limb amputation; fully funding offloading devices such as total contact casts and therapeutic footware would drastically reduce that number. The Canadian Diabetic Association estimates that the government would save $48 - $75 million per year. RNAO calls for a comprehensive approach to prevention of diabetic foot ulcers, with universal access to preventive foot care services for Ontarians living with diabetes; that includes full coverage of offloading devices. Our submission also calls for that population to receive at least one foot assessment per year by a qualified health provider and a province-wide interprofessional approach to diabetic foot care.
Canadian medicare is another example. It covers only hospitals and essential medical care, which is very expensive, and largely downstream. This incomplete medicare program is an historical accident, which a new national health accord could fix. The current arrangement encourages over-investment in costly acute care and medical care, and under-investment in other parts of the health system, including primary care, home care and long-term care. In general, people would rather receive care closer to where they live, but often they end up in hospitals because the other services are less readily available, or only available at considerable expense to the user. Ironically, despite the large government expenditure on hospitals, wait times problems persist because many people are stranded in hospitals waiting for limited placements in the community. We encourage Ontario to continue its negotiations with federal government to address gaps in medicare – most particularly: pharmacare, home care and mental health. In the meantime, we urge the province to initiate its own pharmacare program.
An upstream and more integrated approach to health care would anchor it in primary care, with multidisciplinary teams providing direct care and coordinating system navigation for clients whose needs must be met in other parts of the health system. The government has been expanding access to interprofessional primary care, including the creation of 25 nurse practitioner-led clinics, and that is a major step. Other interprofessional primary care models include 75 Community Health Centres, 10 Aboriginal Health Access Centres, and 186 Family Health Teams. We urge you to fund these existing models so they can hire sufficient staff to work to capacity.
We also note the opportunity to transition 4,100 case coordinators currently working in Community Care Access Centres (CCACs) into true care coordinators in primary care. That full complement of care coordinators would allow for seamless transitions, enhanced communication, timely follow-up and referrals, and decreased duplication. And it would ensure that clients don’t fall through the cracks. The Local Health Integration Networks (LHINs) could coordinate other functions currently done by CCACs.
Allocating resources to the right sectors and right providers is crucial, but a sustainable health human resource strategy is also essential. You need the right mix of health providers with sufficient staffing to safely meet the health care needs of Ontarians. RNAO recommends a permanent table to discuss interprofessional health human resource (HHR) planning, with key professions represented. Until a comprehensive HHR plan is developed, RNAO calls for a moratorium on nursing skill mix changes. Many RN positions have been replaced in situations where we believe the skills and competencies of an RN were required. To address the growing acuity in the hospital sector, we request legislating an all-RN nursing workforce in tertiary, quaternary and cancer centres within two years (Groups A and D), and in large community hospitals (Group B) within five years. We also ask the following minimum staffing standards in long-term care: one attending NP per 120 residents, and a mix of 20 per cent RNs, 25 per cent RPNs and 55 per cent personal support workers.
We also recommend the government mandate LHINs to use models of nursing care that promote continuity of care and care giver. And, in the interests of continuity of care and quality nursing care, we urge the government to meet its goal of 70 per cent full-time employment for RNs.
Using health providers to their full scope and expanding that scope can also enhance access to care and improve system efficiency. In the case of nurse practitioners, we request the following: removing barriers that prevent them from prescribing controlled substances; authorizing them to act as most responsible provider in all sectors, implementing their legislated authority to admit, treat, transfer and discharge hospital in-patients; and fully utilizing the NP-anaesthesia role inclusive of intraoperative care. In the case of RNs, we request implementation of a model of independent RN prescribing and immediately developing the continuing education course to enable it.
As much as possible, our health care system should also focus on prevention and keeping people healthy, while maintaining the capacity to help them navigate to the right level of care when necessary. But better still is to keep people well enough that they don’t need to use the health-care system. That means addressing the social and environmental determinants of health. Investments in those areas not only help people thrive and avoid health costs. They also enhance productivity and reduce burdens on the social safety net and on the justice system.
Most urgently, the federal and provincial government must work in partnership with the Chiefs of Ontario, Indigenous communities and their leaders to provide funding for safe water, reliable sanitation, affordable housing and accessible, high quality health care.
The correlation between poverty and ill health is very strong. We ask for a multipronged strategy, including:
- Raising social assistance rates to reflect the cost of living. We endorse the call for a $1 billion investment in social assistance as a first step.
- Providing a basic income pilot project, but with strong ethical safeguards that ensure that no participant is worse off and that preserves the current social safety net.
- Raising the minimum wage to $15/hour, with no exemptions regarding age or sector
- Investing one per cent of the budget in affordable housing (about $1.39 billion)
To protect the growing section of the workforce in precarious employment, ensure that all workers have the same protections and benefits enjoyed by workers with standard employment.
Other measures to protect vulnerable populations include:
- Implementing a provincial alcohol strategy that promotes better health outcomes
- Funding supervised injection services in communities where needed
- Investing $10 million to promote oral health for low income adults and seniors.
Finally, we urge the government to take the next step in addressing environmental determinants of health. We applaud the province for setting ambitious but attainable greenhouse gas emission targets, which bring huge health co-benefits. The government must ensure that its cap-and-trade mechanism is sufficiently strong that those targets can be reached. In particular, the cap must be set low enough and linkages to other markets must only happen when they maintain Ontario standards.
All sectors must help in reaching the targets, including transportation. Ontario should work with federal and municipal partners to ensure sufficient sustainable revenue are there to pay for a substantial expansion and ongoing operation of public transit and active transportation.
In conclusion, RNAO calls for the budget to be written with a health lens, and with a view to investment in upstream solutions.
We thank you for this opportunity to express the views of RNs, NPs and nursing students on the Ontario budget.