Policy and Political Action

Policy & Political Action

Ontario Pre-Budget 2017: Nurses call for an Upstream Strategy

At a pre-budget consultation in Brampton on Jan. 19, the Registered Nurses' Association of Ontario (RNAO) presented 29 recommendations to the Standing Committee on Finance and Economic Affairs.

RNAO estimates the recommendations could save the province millions while investing in the health of Ontarians.

One of our recommendations calls for better wound care practices. Investment in wound prevention and treatment today would save the government millions of dollars and stop hundreds of unnecessary amputations every year for people with diabetes and prevent needless suffering. Pressure relief (offloading) devices -- that cost anywhere between $100 and $1,500 per person -- are not funded by the government. The average cost of an amputation is about $74,000.

Other recommendations include better health promotion, affordable housing, raising the minimum wage, removing practice barriers so NPs can prescribe controlled substances and allowing RNs to write prescriptions to improve timely access to care.

The government is expected to release it budget sometime this spring.

The Registered Nurses’ Association of Ontario (RNAO) is the professional association representing registered nurses (RN), nurse practitioners (NP) and nursing students in all settings and roles across Ontario. It is the strong, credible voice leading the nursing profession to influence and promote healthy public policy. That policy starts with the budget, and RNAO is pleased to have this opportunity to present its views as part of the pre-budget consultation.

Our submission covers six areas: social determinants of health, environmental determinants of health, Medicare, health system transformation, nursing, and fiscal capacity. These areas span the policy spectrum and present a unifying theme in our submission where we offer upstream solutions to keep people healthy and productive. Ultimately, this approach can also save large sums of money for the province and for the government. Short-term budgetary considerations tempt governments to scrimp on investing in a healthier society (e.g., reducing poverty). However, this approach is foolhardy because everyone pays the price for past decisions. Courageous steps towards an upstream approach have been taken by the government (e.g., closing coal plants), and the province is now in a good position to take more steps towards a healthier society.

Summary of Recommendations

A. Social Determinants of Health

  • Federal and provincial governments must work in partnership with the Chiefs of Ontario, Indigenous communities and their leaders to provide funding to ensure safe water, reliable sanitation, affordable housing, and accessible, high quality health care.
  • Act on multiple poverty fronts immediately:
    • Increase Ontario's dangerously low social assistance rates (Ontario Works and the Ontario Disability Assistance Program) to reflect the actual cost of living and index the increased rate for inflation. RNAO supports the recommendation of the Interfaith Social Assistance Reform Coalition (ISARC) and the Income Security Advocacy Centre (ISAC) to invest $1 billion in social assistance in the 2017 budget as a necessary first step. Within this amount, $700 million should be invested in a 10 per cent increase in basic needs and shelter allowance rates. The remaining $300 million should be invested in rule changes to ensure basic fairness, remove punishments, better support relationships and work, and allow savings.
    • Provide a basic income pilot project for Ontario with strong ethical safeguards. Ensure that no participant is worse off and make sure that there is no erosion of the current social safety net for the broader population. In order to support Indigenous health and reconciliation, RNAO particularly supports Hugh Segal's recommendation that the design of a basic income pilot adapted to the realities of Indigenous communities be "under the full prerogative of the First Nations Chiefs of Ontario."
    • Raise the minimum wage to $15 per hour with no exemptions regarding age or sector.
  • Ensure all workers have the same protections and benefits enjoyed by workers with standard employment:
    • Cover all classes of workers and employers under the Employment Standards Act (ESA) and Labour Relations Act. Update those acts to protect all workers, including access to personal emergency leave, paid sick days, and enhanced enforcement of strengthened labour laws.
    • Develop and implement a plan (preferably via changes to the ESA) to deliver the same wages, benefits and working conditions to workers in nonstandard employment as those in standard employment, under the same terms and conditions (e.g., doing the same work with the same seniority).
  • Improve access to affordable housing and stimulate job creation by investing one per cent of Ontario's budget (about $1.39 billion) to address the backlog of existing affordable housing units in need of repair and to create new affordable housing stock.
  • Implement a provincial alcohol strategy policy that is congruent with the public health evidence for better health outcomes:
    • Roll back recent privatization initiatives and establish a moratorium on further privatization of alcohol sales. In light of the critical evidence of increased harm with increased physical availability of alcohol, strengthen government-run retailing systems and monopolies.
    • Strengthen Ontario's minimum pricing structure by raising minimum prices; linking prices to alcohol content so that as alcohol content rises, so does price; and close loopholes to the minimum price.
    • Ban the advertising, promotion, and marketing of alcohol as recommended by the World Health Organization.
  • Fund supervised injection services (SISs) in communities across Ontario where needed. Expedite funding for the proposed supervised injection services in Toronto and Ottawa to address current crisis, and any subsequent SIS needed across the province, as part of existing health services.
  • Invest $10 million to support the first phase of a public program to provide oral health care to low income adults and seniors across the province. This funding should be allocated to maximize use of existing public investments in dental clinic infrastructure in Community Health Centres, Aboriginal Health Access Centres, and Public Health Units.

B. Environmental Determinants of Health

  • To ensure Ontario meets its greenhouse gas (GHG) targets:
    • Set the carbon cap at a level that would deliver GHG reductions on the targeted schedule or earlier.
    • Only link to other cap-and-trade markets when that maintains Ontario standards
    • Make the granting of free or subsidized emission permits highly targeted and temporary.
    • Ensure cap-and-trade revenues are managed transparently with strong public oversight.
  • The government must take all necessary steps to:
    • Work with federal and municipal partners (starting with a transit summit) to ensure sufficient dedicated and sustainable revenue sources to pay for a substantial expansion and ongoing operation of transit and active transportation,
    • Avoid resorting to public asset sales like the privatization of Hydro One to fund transit expansions, and
    • Support cost-effective and expeditious delivery of those expansions, implemented by transparent governance and informed expert opinion.

C. Medicare

  • Implement a made-in-Ontario pharmacare program, while continuing to aggressively advocate for a national pharmacare program covering all medically necessary drugs.
  • Place greater emphasis on prevention of diabetic foot ulcers:
    • Provide universal access to preventative foot care services, including supplying preventative shoes, socks and offloading devices to those in need, free at the point of care, for all Ontarians living with diabetes.
    • Develop policies that enable every Ontarian with diabetes to have at least one foot assessment per year by a qualified health provider;
    • Adopt an Ontario-wide interprofessional approach to diabetic foot care, with at least one multidisciplinary diabetes foot care team, with a well-defined referral pattern, in each Local Health Integration Network (LHIN);
    • Publish, on an annual basis, reliable data on diabetes foot care, using internationally recognized metrics, to assist on-going quality improvement efforts.
    • Provide education for clinicians & patients on the management of diabetic foot complications
  • Implement a complete legislative ban on inbound medical tourism.

D. Health System Transformation

  • Advance an integrated health system that is anchored in primary care. Include all of primary care, public health units, home health-care and support service providers as HSPs under LHSIA.
  • Fund interprofessional care models of primary care (such as NP-led clinics, Community Health Centres, Aboriginal Health Access Centres, and Family Health Teams) so they can hire sufficient staff to work to full capacity.
  • Refrain from advancing policy that positions LHINs as delivering and/or managing health service delivery. Instead, focus the scope of LHINs on whole system planning, integration, funding allocation, monitoring and accountability functions.
  • Fully dissolve CCACs and produce true health system transformation by preventing the automatic transfer of all CCAC functions, processes and resources to the LHINs.
  • Locate the nearly 4,100 CCAC care co-ordinators within primary care, while keeping them employed by LHINs.
  • Mandate tri-partite leadership models incorporating medicine, nursing and one other regulated health profession within each LHIN.

E. Nursing

  • Immediately initiate and support a permanent table to discuss interprofessional HHR planning with key professions to start e.g. nursing and medicine resulting in an evidence-based interprofessional HHR plan to align population health needs and the full scope of practice of all regulated health professions with system priorities in Ontario.
  • Immediately issue a moratorium on nursing skill mix changes until a comprehensive interprofessional HHR plan is completed
  • Mandate LHINs to use organizational models of nursing care delivery that advance care continuity and avoid fragmented care.
  • The MOHLTC, LHINs and employers eliminate all barriers, and enable NPs to practise to full scope, including: prescribing controlled substances; acting as most responsible provider (MRP) in all sectors; implementing their legislated authority to admit, treat, transfer and discharge hospital in-patients; and utilizing fully the NP-anaesthesia role inclusive of intraoperative care.
  • Achieve 70 per cent full-time employment for RNs in Ontario.
  • Sector specific health human resource recommendations:
    • Legislate an all-RN nursing workforce in acute care effective within two years for tertiary, quaternary and cancer centres (Group A and D) and within five years for large community hospitals (Group B);
    • LHINs should mandate that all first home health-care visits be completed by an RN.
    • The MOHLTC should legislate minimum staffing standards in LTC homes: one attending NP per 120 residents, 20 per cent RNs, 25 per cent RPNs and 55 per cent personal support workers.
  • Implement a model of independent RN prescribing and immediately develop the continuing education course to enable this practice.

F. Fiscal Capacity

  • Ensure the fiscal capacity to deliver all essential health, health care, social, and environmental services and infrastructure by building a more progressive tax system. Do not cut taxes.
  • Increase revenue sources that encourage environmental and societal responsibility. Begin by phasing in environmental levies and implementing a cap-and-trade program for carbon emissions.
  • Update the gasoline tax by making it a tax on value rather than on volume.
  • Reject fire sales of publicly-owned Crown Corporations and assets to fund government programs (e.g., Ontario Power Generation and the Liquor Control Board). Halt the further sale of Hydro One shares.

Get the full submission with references below

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