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Fewer Hands

Less Hospital Care

DURHAM

CUPE Research
2016

DA:cope491:djk
Low levels of hospital funding and low levels of hospital staffing

Hospital funding is low in Ontario. But this also means Ontario has limited hospital
capacity. This paper will explore what this means in terms of the amount of care that
hospitals can provide in Ontario compared to the rest of Canada.

$ Canada Hospital Ontario Hospital TROC Hospital

20052006 1,138.74 1,111.69 1,159.43

20062007 1,217.65 1,177.95 1,247.23

20072008 1,283.57 1,230.78 1,321.68

20082009 1,360.87 1,291.74 1,410.25

20092010 1,430.05 1,333.31 1,496.70

20102011 1,515.58 1,368.71 1,613.66

20112012 1,549.05 1,405.52 1,645.36

20122013 1,577.46 1,417.31 1,684.46

20132014 1,587.17 1,409.70 1,704.93

20142015 1,599.12 1,402.00 1,729.07

20152016 1,605.43 1,395.73 1,749.69

Funding: According to the latest data from the Canadian Institute for Health
Information (CIHI), Ontario government funding for hospitals is $1,395.73 per capita.
The rest of Canada (TROC), excluding Ontario, spends $1,749.69 per capita. In other
words, provincial and territorial governments outside of Ontario spend $353.96 more
per person on hospitals than Ontario does. That is a whopping 25.3% more than
Ontario. That is up 2% from the 23.3% gap in the previous year. Ten years ago, in
2005-2006 the gap was only 4.3%.

This gap, of course, has significant consequences for local communities. Average
Ontario hospital funding for the population the size of Durham 2005-2006 would have
been about $29 million less than average funding for the same population outside of
Ontario. But by 2015-2016 the funding shortfall for a population the size of Durham
would have exploded to $215.3 million. (608,124 people * $353.96 = $215,251,571.04)

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For many years, Ontario
closely followed Canada-
wide funding patterns
but Ontario has fallen
quite a long way behind
since the Liberals were
elected in 2003 and
especially since the
beginning of Liberal
austerity in 2010. With
hospital funding on a
downward track in
Ontario, that gap will
continue to grow.

Hospital funding is falling: Notably, according to CIHIs latest figures, Ontario


government per capita expenditures on hospitals has declined for the last three years
by 1.5%.
Of course hospital services are also affected by
inflation, like other services. CIHI accounts for
health care inflation through the government current
expenditure implicit price index. Between 2012 and
2015 this index increased 6.1%.

Funding would have to increase $1503.77 per capita


just to provide the same level of hospital service.
Instead the government expended just $1395.73.

In other words, in three short years, the government has reduced real spending on
hospital services by 7.2% per person ($1395.73 / $1503.77). If we considered the
impact of an aging population on hospital costs (usually put at about 1% per year in
extra costs), the real cut in funding would be in excess of 10% in just 3 years.

In Canada provincial/territorial hospital funding continues to increase on a per person


basis. Over the same period, provincial government hospital funding increased across
the rest of Canada by $65.23 or 3.9%. Not enough to off-set inflation to be sure, but
much more than the 1.5% decrease in Ontario.

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Does funding in other sectors make up for hospital under-funding?
Funding for the four funding categories
most relevant to hospital funding also
falls short in Ontario. Funding for other
Other health institutions
health care institutions (e.g. long-term per capita funding 2015-16
care facilities) does not make up for the
lack of spending on hospitals in Ontario. $460
452.90
$450
Quite the reverse. Ontario currently $440
(2015-2016) funds 7.2% less than the $430 420.49
cross-Canada average. $420
$410
$400
Ontario also falls behind Canada in OTHER INSTITUTIONS - ONTARIO OTHER INST.
funding the other health care category CANADA-WIDE
(e.g. home and community care),
funding 14.3% less than Canada as a
whole despite all the claims by the Other health care per capita funding 2015-16
Ontario government about investing in
home and community care. Ontario fell 207.32
behind in this category just around the $210
time the Liberals came to power and, $200
$190 177.61
during the reign of the Liberal $180
government, the gap in funding between $170
$160
Canada and Ontario has remained large. Other Health Ontario Other Health
Similarly, funding for health care capital Funding -- Canada- Care Funding
projects (importantly including hospitals) wide
has fallen in recent years and is now far
back compared with the rest of Canada.

Canada-Ontario Health Spending Per-Capita Comparisons


$400
$350
$300
$250
$200
$150
$100
$50
$0

Canada: Drugs Ontario: Drugs Canada: Capital Ontario: Capital

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Health care administrative funding is low in Ontario compared to the Canada-wide
average. For the last number of years administrative costs of provincial public health
insurance have actually been flat.

In fact, administrative funding has fallen


in Ontario from 2.6% of total provincial
health care funding in 1974-1975 to
0.9% in 2015-2016. Across Canada,
administrative funding has declined almost
as quickly, going from 2.6% to 1.1% over
the same period. Low health care
administrative costs is one of the main
ways that public health insurance is more
efficient than the private health insurance
system that dominates the USA, and this
data suggests that as time passes Canada (and Ontario) are gaining even more benefit
from this advantage.

In contrast, profit taking, administrative costs and other non-benefit costs for private
health insurance have dramatically increased. Benefit payouts as a share of premium
costs are hitting new lows. Since 1991, the amount paid out in benefits by these
plans has declined from 92% to 74% in 2011. The rest goes for profits,
administration, and other items. While this is bad, plans purchased from for-profit
insurance corporations by individuals do much worse, with benefits paid declining from
46% to 38% of premiums.1

Funding for drugs


and doctors partially Provincial per capita funding of physicians
offsets the trend to $1,000
the low level of $900
provincial funding: $800
Overspending on $700
areas not so closely $600
connected with $500
hospital funding does $400
occur. Ontario over- $300
funding of physicians $200
continues, currently at $100
$0
2.5% more per-capita
than the Canada-wide
average. This,
however, is a marked
improvement from the Canada Ontario
12.5% gap that

1Michael Law et. al, The Increasing inefficiency of private health insurance in Canada, Canadian Medical Association Journal,
September 2, 2014.
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existed in 2008-2009. Indeed, in the most recent year reported (2015-2016) there was
a modest decline in funding per-capita by Ontario on physicians. Ontario also spends
more than the Canada-wide average on drugs and Public Health.

Overall health care funding by the province: In total, after years of closely tracking
the health care
spending of other Provincial per capita health care funding
provincial governments,
$4,500
Ontario government $4,000
health care funding is $3,500
now falling quite far $3,000
$2,500
behind the Canadian $2,000
average with the $1,500
other provincial and $1,000
$500
territorial governments $0
funding health care
12.7% more per person
on average.
The rest of Canada Ontario
For decades Ontario
health care funding
tracked funding in the rest of Canada. But just as with hospital funding, the gap
between Ontario and the rest of Canada started just when the Ontario government
moved to a policy of austerity. The gap is now growing at a rapid pace.

Ontario health care


under-funding is Provincial per capita health care
primarily driven by
under-funding of funding
hospitals. Hospital
$4,206
funding accounts for $4,165
75% of the under- $4,071
spending ($353 dollars $3,988
$3,914
out of the total per $3,819
capita shortfall of $475).
Indeed, total health care
$3,608
under-funding has
grown in tandem with $3,731 $3,734 $3,755 $3,731
$3,709
the decline in funding for $3,630
hospitals in recent $3,532
years.
20092010 20102011 20112012 20122013 20132014 20142015 20152016
The province of Ontario
spends more on The rest of Canada Ontario
drugs, doctors, and
public health, but less on other health institutions, health care administration, health
care capital projects, and other health care spending.
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But, above all, Ontario funds hospitals less.

The impact of low hospital funding


The connection between low hospital
funding and the low number of hospital
beds in Ontario is well known.

Hospital Beds: Ontario has 2.34 hospital


beds per thousand population, while
Canada as a whole has 3.24, or about
38% more per capita. The rich nations of
the Organization for Economic Cooperation
and Development (OECD) have 4.8 beds
per 1000 population, more than twice the
Ontario number.

In 1990, according to OECD data, the OECD countries had on average 10% more beds
per capita than Canada. By 2000, that had increased to 47% more beds. By 2005,
71% more. And by 2012, the OECD countries had 78% more hospital beds per capita
than Canada. OECD countries had 108% more hospital beds per capita than Ontario
by 2012.

Length of hospital stay is also


declining rapidly in Ontario.
Since 2007-2008 length of stay
has declined one full day in
Ontario a 14.9% decline.

In the last single year reported


(2014-2015) the age
standardized lengths of stay
declined half a day in Ontario
or by 8.1%.

The gap with the Canadian


average has grown from 0.6
fewer days in Ontario in 2007-
2008 to 1.2 fewer days in
Ontario. In 2007-2008 the
Canadian average stay for an
age standardized patient was
8.9% longer, but in 2014-2015
that had grown to 21% longer.

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Hospital inpatient
days: The rest of
Canada had 2.6% more
inpatient days per
person compared to
Ontario; but by 2013-
2014 that gap had
grown almost 8-fold to
20.5% more inpatient
days per person.

Hospital Admissions:
Similarly hospital
admissions are also in
free fall, with a 10% drop
over the last 14 years.

Readmissions: Readmission percentage Canadian Institute for Health


Some publicity has Information
also been given to 9.2
the connection 9
between decreasing 8.8
funding and
8.6
increasing Ontario
8.4
readmission rates.
Ontario hospital 8.2
readmissions are 8
increasing and have 2009-10 20102011 20112012 20122013 20132014 20142015
gone from being Ontario The rest of Canada
lower than the
Canadian average
for readmissions in
2009-2010 (at 8.3
per 100 patients) to
higher than average
readmissions (9.1
per 100 patients).
Notably, Lakeridge
hospital has higher
than average
readmissions.

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Caring hands: Behind all of these problems is not a shortage of beds. Beds
themselves are not expensive in the overall scheme of hospital funding. By far the
largest portion of hospital funding goes for staffing. Low funding means low level of
staffing and that means that fewer beds can be staffed, fewer patients can be taken
care of, and less care can be provided to each patient.

Hospital employees in Ontario form a much smaller part of the population than in the
rest of Canada in
2015 about 0.33%
less of the
population than in
the rest of Canada.
As a result, if
Ontario had the
same percentage of
the population as
the rest of Canada
working in hospitals,
there would be
an additional
45,500 hospital
employees in
Ontario.

This means that on average for every 100,000 people, there are 330 fewer hospital
positions in Ontario. For a population the size of Durham (608,124 in 2011) that would
mean 2,007 fewer people providing care in the hospitals.

Health Care employees in Ontario as a whole also fall behind health care employees in
the rest of Canada. In 2015, Ontario health care employees were 4.01% of the
population while they were 4.31% in the rest of Canada. We fall about 0.30% of the
population behind. Put another way, we would need another 41,300 health care
employees to match the rest of Canada.

In other words, the low Other health employees as % of population


level of hospital workers Ont. Ambulatory
in Ontario accounts for 1.50%
Care
the low level of health TROC
care workers in Ontario. Ont. Nursing and Ambulatory Care
1.00% Residential Care TROC Nursing
Nursing and Residential and Residential
Care
Care employees are also
0.50%
somewhat under- Ontario and the rest of Canada (TROC)
represented in Ontario
(Ontario would have an additional 9,600 employees in this sector if we had similar
staffing as in other provinces), but the largely privatized ambulatory care sector shrinks
the overall gap.
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Nursing

This overall staffing trend is reflected in nursing care in Ontario hospitals. This is
particularly marked in terms of practical nurses (RPNs in Ontario). For that category of
nurses, the rest of Canada has 30% more practical nurses than Ontario. That would
mean another 4,700 practical nurses in Ontario hospitals.

HOSPITAL PRACTICAL NURSES PER 1000


PEOPLE 2015
1.50 1.47
1.40
1.30
1.20 1.13
1.10
1.00
0.90

ONTARIO
THE REST OF
CANADA

The gap between Ontario and the rest of Canada is a less extreme for RNs, with the
rest of Canada having only 17% more hospital RNs than in Ontario. Given the number
of RNs in hospitals, however, this would mean another 10,500 registered nurses in
Ontario hospitals.

HOSPITAL RNS PER 1000


PEOPLE 2015
5.60 5.28
5.10
4.50
4.60

4.10

3.60

3.10

2.60
Ontario The rest of Canada

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In total, there are 19.71% more nurses (practical nurses and registered nurses
combined) in the hospitals in the rest of Canada than in Ontario hospitals. Ontario is
missing 1.11 hospital nurses per 1,000 population compared to the rest of Canada.
With a population of 13,782,341 in 2015 that means Ontario is missing over 15,200
nurses in our hospitals compared to the amount of hospital nursing care in the rest of
Canada. On average, for a population the size of Durham that would mean an extra
675 hospital nurses.

HOSPITAL NURSES PER 1000


PEOPLE 2015
7.00 6.74

6.50
6.00 5.63
5.50
5.00
4.50
4.00
3.50
Ontario The rest of Canada

For patients this means a lot less nursing care. Ontario has a full 6.1 hours less care by
personnel in nursing units than the Canada-wide average (including Ontario). And the
gap between Ontario and the rest of Canada is growing.

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Nursing Inpatient Services Total Worked Hours per Weighted Case

2007-2008 2008-2009 2009-2010 2010-2011 2011-2012

NFLD 52.2 53.26 54.48 55.9 52.9

PEI 83.48 N/R 62.19 62.46 61.66

N. S. 56.79 57.34 U U 54.95

N.B. 54.98 55.46 56.26 57.29 58.13

Quebec 49.73 50.06 50.82 50.73 52.47

Ontario 44.98 44.76 43.71 42.81 42.88

Manitoba 54.41 54.27 53.87 53.06 53.97

Saskatchewan 49.37 51.42 51.28 52.95 54.18

Alberta 54.12 54.65 54.52 54.24 54.36

B.C. 44.24 45.27 45.03 45.87 46.27

NWT U 83.05 88.51 69.48 N/R

Yukon 48.84 48.97 50.25 56.31 54.51

Weighted
Average 48.59 48.8 48.36 48.2 48.98
Source: CIHI

In 2007-2008, the difference was 3.61 hours. By 2010-2011, it had increased to 5.39
hours. In 2011-2012 it was 6.1 hours. That's a 69% increase in the differential in just
four years.

As Ontario is a big part of the Canada-wide weighted average, the difference between
Ontario and the other provinces must be much more marked than this data reveals.

But even this data shows that on a Canada-wide basis patients get 14.2% more nursing
care than patients just in Ontario. Moreover, in a short period of time, Ontario has fallen
far behind Canada in the amount of hospital care by nursing personnel.

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Hospital Nurse Workforce: 2015 CIHI nurse workforce data.

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