Ontario Pre-budget Submission 2013: Finding the Right Balance
RNAO's Speaking Notes and Submission to the Standing Committee on Finance and Economic Affairs
March 22, 2013
Good morning. 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 understand all too well the impact that budgets have on health and on the nursing profession, and we welcome the opportunity to present to the Standing Committee today. We have a simple message: we want balance in the budget.
• Yes, there must be balance between expenditures and revenue so that the debt and deficits don't get out of hand. But a balanced approach means more:
• A balanced approach also asks what expenditures are necessary to maintain and build a healthy society.
• A balanced approach asks how we pay for those services.
• A balanced approach asks how much debt is appropriate and prudent.
• A balanced approach asks how and when we reduce the debt and deficit, taking into account the state of the economy and the needs of society.
• A balanced approach asks how to rectify problems arising in our market economy, such as:
o Pollution and environmental degradation
These are the kinds of problems that lead to ill-health and the early onset of chronic conditions. They affect all of us, but they affect our most vulnerable populations disproportionately. If we focus on one budgetary objective -- the deficit -- to the exclusion of the others, we contribute to ill health. In addition, an austerity approach will also worsen an already weak economy. Based on a pre-recession employment rates of 63.5 per cent and a 2012 rate of 61.3 per cent, there is a shortfall of 250,000 jobs .
Increasingly, those fortunate enough to have jobs are part-timers who want full-time positions – over 400,000 people, and the majority of those workers are female. That is a lot of slack in the economy, and a lot of hardship. I want to begin with nursing and the budget.
Our nursing recommendations will sustain the RN workforce, maximize their contributions to health care and get the best value out of health care expenditures for Ontario. RNs have experienced on-again, off-again treatment at budget time. In the middle 1990s, they were likened to hula hoops by the then Premier of the day and let go in their thousands. Many RNs educated at public expense had to seek employment south of the border, and it proved impossible – despite the costly efforts -- to bring them back. RN workloads soared, and burnout led to increases in sick time, agency use, and a vicious downward spiral that hurt patients, RNs and health-care organizations. Recognizing the error, the McGuinty government worked to undo the damage by committing to hire thousands of nurses. The strategy worked, and nurse-to-population ratios started improving. However, the 2008 recession led to austerity measures that fell particularly hard on RNs, and the result for the last two years has been a decline in RN employment. Ontario has the second worse RN-to population-ratio in the country. And Ontario needs almost 17,000 more RNs to catch up with the rest of the country.
Recommendation 1. Add 9,000 RN FTEs by 2015, in order to start the catch-up with the rest of the country.
Recommendation 2. Reach the desired provincial target of 70 per cent full time employment for all nurses, so that patients have continuity in their care and care provider.
Certain sectors such as home care have less attractive compensation for nurses, which causes recruitment and retention problems in those sectors.
Recommendation 3. Secure fair wages for nurses and nurse practitioners working in all sectors of health care.
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.
Recommendation 4. Maximize and expand the role of RNs to deliver a broader range of care, such as ordering lab tests and prescribing medications.
Recommendation 5. Ensure all existing nurse-practitioner-led clinics are funded to operate to full capacity, and open new nurse practitioner-led-clinics where patient need exists.
Recommendation 6. 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 150 residents.
Recommendation 7. Improve navigation across our complex system by partnering with patients to co-ordinate their care through primary care in community health centres, nurse practitioner-led clinics, and family health teams.
Recommendation 8. Commit to providing all Ontarians with access to integrated inter-professional primary care by 2020.
To ensure coordination between the various elements of our health system, we must secure system integration and decrease duplication. To achieve this, we ask that government:
Recommendation 9. Support Local Health Integration Networks 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 10. Transition the 3,500 Case Managers and Care Coordinators from Community Care Access Centres into primary care, through a carefully crafted labour management strategy that retains their salary and benefits. And, work towards eliminating Community Care Access Centres by 2015.
Social Determinants of Health
There is a strong 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.
Ontario may be facing economic challenges, but this is no excuse to tolerate the high levels of poverty, particularly in First Nations.
The good news is that we know public policy can make a difference in people’s day-to-day lives and improve health outcomes. Ontario’s first Poverty Reduction Strategy was released in December 2008. Early investments in increasing the Ontario Child Benefit helped reduce the number of children living in poverty by 29,000 in 2010 compared with 2008 despite the global economic recession. 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 a significant boon to the working poor. Working should be a pathway out of poverty and the current wage still falls 10 per cent below the poverty line. 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. We offer three recommendations:
Recommendation 11. Transform the social assistance system to reflect the actual cost of living.
Recommendation 12. Improve access to affordable housing by leading in negotiating a federal-provincial long-term affordable housing agreement. Commit at least $132 million annually to the agreement. And, by capitalizing the affordable housing loan fund at Infrastructure Ontario by an additional $500 million.
Recommendation 13. Increase the minimum wage to 11.50 in 2013, $12.75 in 2014, and $14.50 in 2015, and automatically index it to the rate of inflation thereafter
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. Two of the three remaining plants are slated to shut down in 2013 and the last one is scheduled to close in 2014. Ontario will be the first North American jurisdiction to completely close its coal plants. 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.
Recommendation 14. Close the remaining coal plants as soon as possible. This will be a cost-saving measure.
Recommendation 15. 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.
Our publicly-insured health-care system faces periodic stresses, 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 CHA. These areas tend to be less well developed as a result. When public money is scarce, private money may show up, but at a price. For example, we are aware of medical tourists jumping the queue in Ontario. While we understand the temptation to take the money, this is a dangerous violation of the principle of universal access – with Ontarians needing to move down the queue to accommodate well-heeled patients from abroad.
Recommendation 16. Commit to and expand our publicly funded, not-for-profit health-care system in areas such as home care.
Recommendation 17. Reject efforts to commercialize or privatize health-care delivery, and immediately stop revenue creation from “medical tourism.”
Recommendation 18. Focus on well-researched and demonstrated policies and evidence-based clinical practices to optimize the health of people, families, communities, and our health system.
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 behooves all of us to find ways for the government to pay for them. And we have recommendations to do just that.
Recommendation 19. 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.
Recommendation 20. Tax evasion and tax avoidance cost provincial governments a great deal of money. Work with the federal government to research the scope of these losses, and then put in resources to recover the lost revenues.
Recommendation 21. Phase 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.
We wish to thank the Standing Committee for giving us this opportunity to present the views of the registered nurse profession on the budget.
To see RNAO's Speaking Notes and Submission to the Standing Committee on Finance and Economic Affairs, please see below.