Policy and Political Action

Policy & Political Action

RNAO speaking notes for Ontario Pre-Budget Submission 2018: Improving Ontarians’ health and healthcare

For the full speaking notes with attachments, references and appendices please see attached PDF

Good afternoon. My name is Doris Grinspun, and I am the CEO of the Registered Nurses' Association of Ontario (RNAO).

I would like to begin this presentation by urging the provincial government to use a health-in-all-policies philosophy when formulating the 2018 budget. This means promoting an upstream approach that invests in wellness and avoids the human and economic costs of avoidable illness, injury and death. The end result is a healthier society, a healthier economy and a healthier budget balance.

RNAO's budgetary requests today will cover four categories: nursing, medicare, social determinants of health, and environmental determinants of health. I will conclude with a discussion of how to pay for these recommendations.
First, let's discuss nursing.  

To maximize health system efficiency and patient outcomes, it is essential that Registered Nurses (RNs) and Nurse Practitioners (NPs) work to their full scope of practice and are used optimally. In the case of RNs, we ask the government to ensure LHINs follow-up on the Minister's 2017 mandate letter and guidance document and locate care co-ordination and care co-ordinators in primary care settings. This will enhance primary care providers' ability to co-ordinate their patients' care, and help anchor Ontario's health system in primary care, which is a hallmark of the world's most effective health systems.

Much progress has been made to advance the authority of NPs with regard to ordering and applying ultrasound, ordering x-rays, and prescribing controlled substances. We ask the government to move promptly to allow NPs to: perform point-of-care testing, order all diagnostic imaging; order ECGs in all situations; certify a death; and complete legal forms for mental health services.

Ontario has a shortage of RN positions. Our province has the lowest RN-to-population ratio in Canada, and needs at least 19,000 more RN jobs to catch up. It is also important to have the right mix of nurses, especially given the rising acuity of patients in hospitals, long-term care and home care. Since RNs are required for complex patients, this avoidable shortfall of RN positions has caused a growing mismatch between patient needs and the type of nursing care they receive. Accordingly, RNAO asks the province to immediately ensure that all new nursing hires in tertiary, quaternary and cancer care centres to be RNs. We also ask that all first home care visits be provided by an RN. 

At the system level, Government must address current LTC funding models that unintentionally discourage improvements in patient outcomes, because funding drops when homes are able to lower patient acuity by preventing health problems. We recommend the province review and transform funding models in LTC to support improved resident care. In particular, consider putting resident improvement funding in place, rather than penalizing homes for improving resident outcomes.

Ontario's aging population presents important but manageable challenges. The province's long-term care homes face a more complex population and growing wait lists. To help the LTC sector meet these demands, RNAO requests the province legislate minimum staffing and skill mix standards in LTC, accompanied by the necessary funding to support this change. We urge no less than one attending NP for every 120 residents, and a staff mix consisting of 20 per cent RNs, 25 per cent RPNs, and 55 per cent PSWs.

Now I would like to discuss improvements to medicare. Canada has the unfortunate distinction of being the only developed country with a universal health system that does not also have a universal pharmacare program. Though we were encouraged that Ontario launched OHIP Plus earlier this year, we ask government to go further and put in place a universal, single-payer pharmacare program in Ontario covering all medically necessary drugs and associated products, with no means testing, co-payments or deductibles for Ontarians of all ages. This will result in more efficient use of the health system, save money through bulk purchasing, and ensure no Ontarian has to choose between buying essential medication and putting food on their family's table. By taking the lead on pharmacare, Ontario could also inspire progress toward a national pharmacare program.

Another area where medicare can be improved is oral health. About 17% of our province's population cannot afford dental care, and must turn to more costly and less effective health services. As an initial step forward, we encourage the province to invest $10 million to support the first phase of a public program to provide oral health care to adults and seniors living with low income across the province.

We must leverage technology and mandate that electronic personal health records (PHR) be made available to patients in order to increase access to medical information and encourage patient participation in health-care decision-making.
To keep Ontarians healthy, we must also address the social determinants of health. And nowhere is this need greater than in Ontario's First Nations communities. We urge the province to partner with Indigenous nations to address urgent health needs identified by them, such as the ongoing crisis of child and youth suicide.

Ontarians across the province benefited from the January increase to the minimum wage, and we urge the government to proceed with the increase to $15 per hour next January. This will help minimum wage workers get closer to a living wage.

Yet too many Ontarians still lack adequate housing, which is a critical obstacle to good health. Thus we are asking the province to invest one per cent of Ontario's budget to address the backlog of existing affordable housing units in need of repair and to create new affordable and accessible housing stock. To meet the needs of vulnerable Ontarians, at least 30,000 units of supportive housing must be created over the next 10 years for people with mental health and addiction issues.

The environment is also a key determinant of health. Ontario has taken major environmental measures such as closing coal-fired power plants, stopping the cosmetic use of chemical pesticides, implementing a reduction in the use of toxics, expanding clean renewable energy, investing in transit and active transportation, and leading the reduction of greenhouse gas emissions. Our full submission details recommendations to continue and strengthen these measures. But today, we would like to reinforce our recommendation to work with federal and municipal partners to ensure dedicated and sustainable revenue sources to pay for ongoing operation and substantial expansion of transit and active transportation in Ontario. Existing revenue sources are not adequate to achieve this task.

It takes money to deliver the programs required for a healthy society, and yet Ontario's per capita program spending is much lower than any province except Quebec. The share of our provincial GDP that goes to program spending is the lowest in the country. What limits the spending is the failure to collect revenue. Ontario collects the second-lowest share of GDP as revenue in Canada, ahead only of oil-rich Alberta. A set of tables at the end of these speaking notes shows the extent to which Ontario is an outlier when it comes to revenue and expenditure.

The size of the budget is a political choice. Ontario has chosen to under-spend, and balance its budget by austerity measures rather than revenue measures.

The following fiscal capacity recommendations highlight a different way forward:

  • Ensure the fiscal capacity to deliver all essential health, health-care, social and environmental services by building a more progressive tax system. Do not cut taxes.
  • Increase revenue sources that encourage environmental and social responsibility. Begin by phasing in environmental levies and continue implementing a cap-and-trade program for carbon emissions.
  • Reject sales of publicly owned crown corporations and assets to fund government programs. Halt the further sale of Hydro One shares.
  • Seize this low-interest, low-deficit opportunity to catch up on investments in human, environmental and physical capital.
  • Ensure transparency and accountability in fiscal measures to deliver services people want and deserve, and to ensure that is done in an efficient manner.


Thank you for this opportunity to present the views of Ontario's RNs, NPs and nursing students. Our full submission with all recommendations is in the packages we provided. I will be pleased to answer any questions.

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RNAO prebudget speaking notes Jan 19894.71 KB
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Speaking Notes