August 12, 2009
It is not realistic, respectful, or democratic to solicit public input to the federal government’s budget priorities and then prevent consideration of thoughtful responses by setting arbitrary constraints such as only considering the first three recommendations presented or only the first part of a multi-part recommendation. Complex global challenges require elaborate, inter-sectoral solutions that engage all Canadians—limiting thoughtful, multi-factoral recommendations to three simple points is a lost opportunity to improve public policy and inspire collective action.
The Registered Nurses’ Association of Ontario (RNAO) is the professional organization for registered nurses who practice in all roles and sectors across Ontario. Our mandate is to advocate for nursing and for healthy public policy, both in Ontario and nationally through membership in the Canadian Nurses Association. We welcome this opportunity to participate in the federal pre-budget consultation and to convey the views and recommendations of Ontario’s registered nurses.
Prior to providing the rationale for our three top recommendations, RNAO would like to provide feedback to the House of Commons Standing Committee on Finance on what we experience as a profound limitation to the consultation process. In the context of unprecedented financial turbulence and global economic difficulties, the Committee asks all interested Canadians to respond to two complex, multi-faceted questions by providing a maximum of three simple recommendations. The Committee warns that they will only consider the first three recommendations presented or only the first part of a multi-part recommendation. It is not realistic, respectful, or democratic to solicit public input to the federal government’s budget priorities and then prevent consideration of thoughtful responses by setting such arbitrary constraints. Complex global challenges require elaborate, inter-sectoral solutions that engage all Canadians—limiting thoughtful, multi-factoral recommendations to three simple points is a lost opportunity to improve public policy and inspire collective action.
Ensure the fiscal capacity to deliver all essential health, social, and environmental services by building a more progressive tax system and revenue sources that encourage environmental and societal responsibility.
Rationale for Recommendation #1:
Taxes Pay for Investments Needed by a Healthy Society
RNAO’s perspective is that current economic challenges make it all the more imperative that the federal government ensure fiscal capacity over the long run to meet its obligations to deliver all necessary physical, environmental and social infrastructure. A modern economy depends upon a healthy, educated population – able to realize its full productive potential. As registered nurses, we know this requires government policies to support all determinants of health, including: sufficient resources to live in health and dignity; social inclusion; housing; healthy environments; and access to health care and education. Through government, we pay to address these determinants using our tax dollars.
The federal government plays a major role, particularly though transfer payments to provinces and territories, for health care, post-secondary education, social assistance, social services, early childhood development and childcare. A long-term downward trend in government program expenditures as a share of GDP helps to explain the large shortfall of investment in physical, social and environmental capital. Between 1983-1984 and 2007-2008, federal program expenditures (including transfer payments to individuals and other levels of government) have dropped from 18.8 per cent of GDP to 13 per cent.This drop has meant cutbacks in services and infrastructure renewal that are critical to maintaining a healthy society.
This drop in expenditures is driven by a decision to balance the budget in the wake of tax cuts, which have made Canada one of the least taxed countries in the OECD. As one study of advanced OECD countries concluded, low tax rates conferred little or no economic advantage, but they came at a high social cost (such as more unequal income distribution and higher rates of poverty). Inevitably, vulnerable populations suffer the most from under-investment in social, environmental and health infrastructure.
The most important tax policy question for RNAO is how to adequately fund important public services. The government must raise enough tax revenue to pay for the services necessary to maintain a healthy society. At the present time, that means reversing tax cuts such as broad-based personal income tax cuts that will cost about $2 billion per year while providing the greatest benefit to those with the highest incomes. Low-income Canadians will receive a maximum of only $33 from broad-based tax cuts, while the average Canadian household can expect a little over $300 and those making over $150,000 will receive $900. Instead, alternative revenue sources such as strengthening green taxes is a more equitable way of raising money that will simultaneously correct certain market inefficiencies.
Ensure that Canadians have access to nursing care by investing $385 million in earmarked conditional transfers for nursing education and to support the creation of 10,000 additional full-time RN positions.
Rationale for Recommendation #2:
Canada Needs to Invest in Nursing Human Resources for Better Health Outcomes and Improved Access to Health Care
Health care is a determinant of health, and access to registered nurses is an essential component for optimal health outcomes. There is clear evidence that demonstrates care provided by registered nurses is associated with better health outcomes in a variety of settings such as hospitals,long-term care,and the community.To take but one example, a systematic review of the literature found that greater RN staffing was associated with lower hospital mortality such that an increase by 1 RN full time equivalent (FTE) per patient day would save 5 lives per 1,000 hospitalized patients in intensive care units, 5 lives per 1,000 hospitalized medical patients, and 6 lives per 1,000 hospitalized surgical patients. Nurse Practitioners (NP) in both primary and acute care settings have been shown to supplement and complement other roles and improve access to health services. In a variety of settings, RNs and NPs have proved beneficial to clients with chronic care conditions by successfully decreasing utilization of health-care resources, improving patient satisfaction, and improving quality of life.
Canada’s RN workforce is aging. In 2007, the average age of a RN employed in nursing was 45.1 years compared with the average age in 2001 of 43.3 years. In 2007, 22.0 per cent were over 54 years of age, which is close to an average age of retirement for nurses. At the same time, the RN workforce is lagging in size behind population growth, with the number of RNs/10,000 population being 78.2, which is well below the 80.8 RNs/10,000 level in 1994. With an aging nursing workforce serving the needs of a growing and aging population, efforts are required to retain the current workforce; absorb and retain new graduates; attract more individuals to nursing; and, reduce workloads.
The Canadian Nurses Association estimates that there was a shortage of nearly 11,000 FTE RNs in Canada in 2007. They predict that if the health needs of Canadians continue to change according to past trends, the shortage of RNs in Canada will increase to almost 60,000 FTEs by 2022 if no policy interventions are implemented. Fortunately, there are policy interventions at hand that the federal government has the opportunity to fund in order to ensure that Canadians have access to nursing care.
Support for nursing education and the resulting number of graduates from nursing programs are a function of policy choices and political will. In 2007, the number of entry-to-practice nursing graduates in Canada reached 9,447. This was the first time in 30 years that the number exceeded 9,000. Over this time period, Canada’s population has grown by approximately 39 per cent. In 1971 and 1972, there were 10,058 and 10,083 graduates respectively from Canadian nursing programs. Recent policy choices are starting to make a difference. In Canada, there was a 12.7 per cent increase in the number of graduates from entry-to-practice nursing programs between 2006 and 2007. The largest increase was in Ontario with a 40.3 per cent increase as there were 2,828 nursing graduates from entry-to-practice programs in 2007 compared with 2,015 in 2006.
The Canadian Nurses Association estimates that Canada needs to graduate at least 12,000 nursing students per year in order to keep up with population growth and attrition.With additional resources, it is anticipated that 70 per cent of RN programs could expand their enrolment by 25 per cent. The Canadian Association of Schools of Nursing estimates an annual need for 3,673 nurses with master’s degrees and 650 nurses with doctoral degrees. In 2007, only 603 master’s degrees were granted, and 44 PhDs – 16.4 per cent and 6.8 per cent of the required totals, respectively. A massive effort is required in order to have faculty to teach the needed increase in nursing students, especially as nursing faculty are nearing retirement in increasing numbers.
RNAO has advocated, with notable success, for 70 per cent full-time RN employment since 2000. Excessive utilization of part-time and casual employment for RNs has been associated with decreased morale and disengagement among nurses, and lack of continuity of care for patients.Higher proportions of full-time RN staff are associated with lower mortality rates, improved quality of care, and cost savings. RNAO’s 2005 survey, The 70 Per Cent Solution, found the strongest progress in full-time RN employment took place in the hospital sector, which had conditional, targeted funding. The percentage of Ontario RNs employed full-time has been rising from a low of 50 per cent in 1998 to 64.7 per cent in 2008. Achieving 70 per cent full-time work across the national nursing workforce will require more targeted, conditional funding for the hospital sector, and the introduction of such funding to the long-term care and home care sectors.
The federal government must contribute to solving this problem by providing for investments in key areas to retain existing RNs and deliver a new generation of RNs. Multiple challenges require investment in several areas including creation of full time positions for RNs; nursing education infrastructure; support for faculty education and faculty positions; increased number of nursing seats; and increased access to clinical placements for students. RNAO recommends that the federal government invest $135 million funding in earmarked conditional transfers for nursing education and to support the creation of 10,000 new full-time RN positions.
Ensurethat unemployed Canadians in this time of economic turmoil will be able to access Canada’s Employment Insurance (EI) system by expanding eligibility and improving benefit levels.
Rationale for Recommendation #3:
Employment Insurance is a critical component of preventing unemployed workers from the detrimental health impacts of poverty while serving as an economic stimulus for local communities.