The long series of failures of private clinics in Ontario

For many years, OCHU/CUPE has been concerned the Ontario government would transfer public hospital surgeries, procedures and diagnostic tests to private clinics. CUPE began campaigning in earnest against this possibility in the spring of 2007 with a tour of the province by former British Health Secretary, Frank Dobson, who talked about the disastrous British experience with private surgical clinics.

Health care privatization in CanadaThe door opened years ago with the introduction of fee-for-service hospital funding (sometimes called Quality Based Funding). Then in the fall of 2013 the government announced regulatory changes to facilitate this privatization. The government announced Request for Proposals for the summer of 2014 to expand the role of "Independent Health Facilities" (IHFs). 

With mass campaigns to stop the private clinic expansion by the Ontario Health Coalition the process slowed.  

But it seems the provincial Liberal government continues to push the idea.  Following a recent second OCHU tour with Frank Dobson, a ministry spokesperson told the Hamilton Spectator"The province hasn't yet "shifted low-risk procedures to out-of-hospital clinics". However, with the shift, the ministry hopes to provide patients with "quicker access to complex surgeries because hospitals will be able to get to more complex procedures sooner."

Health Quality Ontario (HQO) is conducting a review of oversight programs to improve non-hospital clinics, the Ministry spokesperson noted. "The ministry will review HQO's recommendations to ensure sufficient quality oversight is in place prior to moving low-risk procedures into out-of-hospital clinics."

The ministry's claim that it has not shifted procedures to out of hospital clinics is not exactly true -- we have only slowed down the transfer of work to IHFs, other sorts of private clinics have been taking hospital and other work for years.  The IHF gambit is just the latest attempt to expand the role of privatized health clinics. 

And, as set out below, that history is replete with problems.

The unpromising history:  Hospitals are the main focus of the government’s health care cuts. They do not see community hospitals as providing a broad range of services to the local population, but instead wish to remove an untold range of services from local hospitals and transfer them to specialized private clinics. The proposal would remove the most lucrative, high volume and easiest procedures from community hospitals. The remaining community hospitals would be left with the most difficult services. If they chose to compete with the private clinics, they would have to specialize in a narrow range of services. The government’s plan is the opposite of one-stop, integrated public health care.

This proposed privatization of surgeries and diagnostic tests is in addition to the aggressive attempts to remove non-acute care services from hospitals (e.g. outpatient clinics, complex continuing care, rehabilitation, long-term care, primary care, etc.). As acute care currently accounts for only about 1/3 of current hospital funding, these attacks are a grave threat to the viability of community hospitals, and in fact we are now seeing a wave of hospital shut-downs that is somewhat reminiscent of the Mike Harris era.

Despite the government’s rhetoric about keeping care non-profit, services that are being cut from local hospitals now are being privatized to for-profit owned corporations. Even if the private clinics did start out as non-profit (which has not been the case so far) the whole system of private clinics could be privatized with a stroke of a pen.

Ontario Health Care Privatization: The push for health care privatization in Ontario picked up in 2001 when Ontario Health Minister Tony Clement announced two privatized P3 hospital projects, the Royal Ottawa and the Brampton Civic (part of William Osler Health Centre). Spirited community-based campaigns, including P3 plebiscites in many towns, forced the Liberal government to greatly narrow the scope of the privatization of support jobs (i.e. CUPE jobs) in subsequent P3 hospitals. Nevertheless privatization of the hospital financing continues, despite revelations by the provincial Auditor General that confirmed claims by CUPE and others that the Osler project cost hundreds of millions more due to the P3. A subsequent report from the Auditor General on P3s indicated that billions of dollars have been wasted unnecessarily on these projects, mostly hospitals.

MRI and CT Clinics: The PC government also tried to set up private MRI and CT clinics outside of hospitals. Community/labour campaigns however were able to stop this. A key factor was that, to increase their revenue, the private clinics were allowed to bill private patients for a certain number of hours each week (with the rest of the week dedicated to patients paid for by the public system). As the public insurance system must pay for all ‘medically necessary’ hospital services, the government was left to try to explain why any reputable clinic would allow patients to subject themselves to such tests for medically unnecessary reasons. Since this episode, private clinics have been in the news – but mostly for the wrong reasons.

ORNGE and eHealth Privatization Scandals: Privatization scandals continued with ORNGE and eHealth. In the latter case, the Auditor General revealed rotten contracting out practices. By 2008, the eHealth Program Branch had almost 300 consultants compared to fewer than 30 full-time employees. “Relying too heavily on consultants can be costly,” the Auditor said. “Consultants are generally a lot more expensive than employees, and when they finish a project, they leave, often taking with them the expertise needed to maintain and operate the system they helped develop.” The eHealth contracting-out scandal helped force out the Health Minister David Caplan, along with the CEO of eHealth, and the board chair of eHealth.

With ORNGE, reports from the Auditor General and others revealed how privatization had been used by a nominally public organization to drive up executive salaries to outrageous levels. Those salaries were kept from public scrutiny through the creation of private corporations. The introduction of private corporations into the business obscured legitimate public oversight, with ORNGE sometimes refusing to provide the Auditor General basic information under the excuse of privatization. Ultimately the disgraced former CEO of ORNGE said “I didn’t perceive our salaries would be compared to other public-sector agencies” rather than private sector salaries. “That was an error.”

Private Surgical and Diagnostic Clinics: Shortly after CUPE warned the province of the dangers of private clinics through the tour of the province by the former British Health Secretary (i.e. Minister) Frank Dobson in the spring of 2007, tragedy struck.

On September 20, 2007, Krista Stryland died after undergoing liposuction at a private clinic. Stryland bled excessively following the surgery. The College found that one of the doctors involved delayed calling 911, and when paramedics finally did arrive, they found Stryland lying in a pool of blood with no vital signs. The family doctor who performed the liposuction was ultimately publicly reprimanded and told that her “dangerous” behaviour was an “obvious betrayal of the public trust.” “Emboldened with time and experience, you proceeded to perform more and more invasive procedures and ultimately major surgeries without the benefit of formal surgical training. ...You put your own interests above your patients,” she was told.

The government had let much of the emerging industry slip entirely free of public reporting and oversight.

After the September 2007 death of Krista Stryland, the government was forced to require the industry to face some modest oversight several years later, in 2010. Unfortunately this was not by a public authority, but through self-regulation by the doctors (even though the doctors themselves had lobbied to expand this private industry).

Moreover, problems kept happening.

In the fall of 2011, following disclosure that 6,800 patients would have to be notified that faulty infection control procedures at a private clinic could have exposed them to HIV or hepatitis, the then Health Minister, Deb Matthews, declined to introduce oversight by a public authority, despite public pressure. Instead she comments, “Government can’t do everything. A professional (regulating body) like the College of Physicians and Surgeons, they take responsibility for their members....At this point I am delighted the College is taking that responsibility seriously and has found a problem that we need to fix.”

Eventually, in 2012, the College of Physicians and Surgeons released a report on "out of hospital premises" (one category of private clinics) that mentions that some 29% of the private clinics fall short in some way – but the College would not indicate which ones – or how they fell short. This caused public uproar, with the Toronto Star playing a leading role (as it would continue to do). Again, the government promised improvements.

The Star followed up and revealed that the public reports from the College of Physicians and Surgeons fall far short. They also ran a series of often front page stories on serious quality problems at private clinics, including stories on life-threatening infections during outbreaks at four Toronto pain and colonoscopy clinics. Toronto Public Health investigated the outbreaks and the College of Physicians and Surgeons inspected the clinics, but their reports were kept secret.

The new Health Minister, Eric Hoskins, ultimately responded by promising improvements of the clinics once again. He told the Toronto Star in the fall of 2014 that he has put the province’s public health units and colleges (including the college of Physicians and Surgeons) on notice that he wants investigation and inspection reports made public. “It is clear that our system must become more transparent,” Hoskins said, adding the new measures will allow Ontarians to find out if clinics have had problems with infection control and whether patients have suffered illnesses or died. Hoskins also reportedly asked for advice on this from Health Quality Ontario, an independent government agency that assesses and reports on quality in different parts of the health system.

The College of Physicians and Surgeons responded by releasing in early 2015 a report which called for itself to take over a single system of oversight of Independent Health Facilities, the Out of Hospital Program, and other clinics as well.

To date, the reports on the Out of Hospital Program on the College’s web site remain the same ― with threadbare comments.

Eight years after Krista Stryland’s death and more than eight years after CUPE warning on the problems of private clinics, the government is still trying to establish some semblance of an adequate oversight for private clinics. (For more on college regulation of the clinics, see the CUPE Fact Sheet Briefing Note for OCHU on College Regulation of Private Clinics.)

Time has run out ― the government should stop this failed experiment.

More Private Clinic Problems: Over the summer of 2013, the government got into a messy dispute with private physiotherapy clinics. The government stopped 94 physiotherapy clinics from directly billing OHIP. Ontario Health Minister Deb Matthews said that, over the years, licences to provide these services have been bought up by large corporations. Moreover, she charged, the “existing 94 clinics have had an unlimited ability to bill the government and have become very creative in the way they bill.” The government claimed that an audit of 15,000 records from the clinics found that 58% of them failed to support OHIP billings. Five-minute exercise classes were sometimes billed as physiotherapy, care plans did not measure up, record keeping was incomplete, and physician referrals were sometimes lacking.

“There is extraordinary growth in expenditures and the audit was one of those factors that just demonstrated to me that there were companies who were just taking advantage of the way the program was set out and taking advantage of their unlimited ability to bill,” then Health Minister Deb Matthews told the Star.

By reforming how the money is distributed, the government claimed they will provide physiotherapy, exercising and fall-prevention classes to 218,000 more people, mostly seniors. And they are going to do this while providing less money for physiotherapy than they otherwise would: $16,000,000 less according to the Toronto Star.

Still More Private Clinic Problems: The government was back at war with another group of private clinics in early 2014, this time the newly established private plasma clinics. The government, opposed to their plan to pay people for their plasma, wanted to shut them down.

But the clinics refused. Indeed, they said they need no license from the government to operate. In the face of this open defiance, the then Health Minister Deb Matthews was reduced to calling in inspectors and threatening to get a court order. New legislation was also threatened. “I expect any company operating in Ontario, and especially in the health care sector, to operate within our laws,” Matthews told the Toronto Star. But she admitted it may take time to shut the clinics down.

The private clinics remained unmoved: “Until that act is passed, the legal opinion we have is we don’t need a licence from the provincial government.” Perhaps they were then hoping that with an election coming a Progressive Conservative government would be more friendly. If so, that hope proved unfulfilled.
Nevertheless, the Liberal government has not yet learned its lesson and announced that it will not encourage more private clinics.

Other Private Clinic Issues:

  • Operations can and do go wrong. In contrast with public hospitals, private specialty clinics are unable to handle many emergencies and simply call 911 for EMS. Will ambulances be able to move patients to hospitals when things go wrong? Indeed, private surgical clinics first came to public attention in Ontario when a young mother, Krista Stryland, died following a procedure. After some delay, the doctor called 911. Paramedics arrived at the clinic to find the patient in a pool of blood and with no vital signs. Is it appropriate to establish a system that inherently requires extra time to effectively treat patients who fall into emergency situations? Will the Ontario government establish a requirement that doctors be on site at all times? Will they require that specialty hospitals have emergency capacities (beyond calling 911)? Will they require the private clinics to disclose to patients the limitations of their emergency abilities? 

  • User fees: The Ontario Health Coalition has revealed widespread extra-billing by existing private clinics. There is little doubt that this will intensify with more private clinic delivery. But Ontario already has the highest share of private payment for health care in the country. Private expenditures in Ontario run to 32.3% of total health expenditures, higher than any other province (Saskatchewan is at only 24% private expenditures). In dollars, private payments for health care are 5.3% higher in Ontario than Canada as a whole, almost $100 more per person per year. Notably, increased private payment does not mean a reduction in public spending: governments in the U.S.A. spend far more money on health care than Canadian governments, both in absolute dollars per capita and as a percentage of the economy. This despite the fact that most Americans have no public insurance and private payment for health care in the U.S.A. far exceeds any other country. 

  • Billing problems are also evident in Quebec. In early 2013, the province decided not to renew the contract with Rockland MD, which has provided about 9,000 publicly funded surgeries since 2008 in Quebec. The public health insurer found that Rockland MD was charging people illegal facility fees. The former British Secretary of Health reports that such clinics in Britain were 11% more expensive than a hospital providing similar services. 

  • Doctors’ incomes: Doctors have lobbied for this new delivery form and it will create a new form of payment for doctors. But the introduction of alternate forms of payment for doctors under the Liberal government has gone hand-in-hand with huge payment increases to doctors, not savings. Since the Liberals were elected in 2003, new (or “alternate”) forms of payment to doctors have increased 430% through to 2011/12. With this increase, doctors have driven up their total clinical payments an astonishing 94%. Ontario spends more per capita on doctors than Canadians as a whole. In contrast Ontario spends less per capita on hospitals than Canadians.


Rapid change in public hospital services

hospital inpatient days decrease over last four years
Canadian Institute for Health Information (CIHI) hospital data indicates big changes in hospital activity, particularly in the most recent four years reported. Ontario, especially, is experimenting with hospital cuts and restructuring.  

Hospital inpatient days are now dropping rapidly in Ontario – with a drop of 13.4% in inpatient days over the last four years. This has occurred even as inpatient days continue to increase in the rest of Canada (note: Quebec is excluded from the CIHI report as the data for that province is under review). 

The data suggests a sharp fall in Ontario in 2013/14 compared to 2012/13 (8.9%), a less sharp decline over the previous 3 years, and significant growth over the previous five year period.

Over the 15 years of data reported (1999/00 through 2013/14), Ontario inpatient days have increased 4.6%  -- even while population has increased at almost four times that rate (17.8 %) and the median age increased 4 full years (from 36.2 to 40.2 years). The rest of Canada has seen much faster growth -- 21.1% more inpatient days, despite only 16.8% population growth and somewhat less than 3.8 years growth in median age. 

Despite a more rapidly growing and more rapidly aging population, Ontario hospital inpatient days are falling further behind the rest of Canada.

hospital inpatient days 1999 through 2014

For the sake of comparison between geographic areas like Ontario and the rest of Canada, services can be compared on the basis of service per person (i.e. service per-capita).  

Ontario had 0.68 inpatient days per person (per-capita) in 2013/14 (with a population of 13.55 million). The rest of Canada excluding Quebec (with a slightly smaller population of 13.45 million) had 0.82 inpatient days per-capita.

In other words, the rest of Canada had 20.5% more inpatient days per person. This is a much bigger gap than existed in 1999/2000 when Ontario had  0.77 days per-person while the rest of Canada had 0.79 days per-person.

As a result, in 1999/2000, the rest of Canada had 2.6% more inpatient days per person compared to Ontario; but by 2013
/14 that gap had grown almost 8-fold to 20.5% more inpatient days per person. 

hospital inpatient days per-capita 2013-14

That's quite a change, with much of it occurring in just the last few years during deep cuts to real hospital funding in Ontario.  Clearly, Ontario provides a lot less inpatient days to its population than the rest of Canada and that trend is deepening.

Also note that Ontario inpatient days per-capita have declined almost 12% between 1999/2000 and 2013/14 (going from 0.77 per-capita to 0.68). (This despite a median population age that is now 4 years older than in 1999/2000.) In the rest of Canada, inpatient days per-capita have actually increased 3.7%. 

Hospital emergency department visits 1999-2014

Increasing emergency visits:
Despite  declining hospital inpatient days, Emergency Room visits continue to increase in Ontario. Indeed they are increasing at a faster pace than in the past.  

However, Ontario has far fewer Emergency Room visits per-capita than the rest of Canada: 0.44 visits per person in 2013/14 versus 0.55. In other words, there are 25% more emergency visits per-capita in the rest of Canada than Ontario.   Even with increased use of Emergency Rooms in Ontario, they are much more highly utilized in the rest of Canada. The idea that Ontario Emergency Rooms are over utilized is not borne out by this statistic. 
Emergency department visits 199-2014, Ontario and Canada

Despite the increased absolute number of emergency visits, Ontario has reduced hospital emergency visits per-capita slightly since 1999/2000 (from 0.45 visits per person to 0.44 per person).  However, all of the reduction occurred in the middle of the last decade and there has been an upward trend in more recent years. Unlike Ontario, the rest of Canada has seen increased emergency room visits per-capita (from 0.52 to 0.55). Again, the upwards trend became even more marked in recent years. 

Ontario hospital inpatient admissions this century

Admissions: Total hospital inpatient admissions have been practically static in Ontario and in the rest of Canada since 1999/00.  

However with a rapidly increasing population in Ontario there has been a consistent and rapid downward trend in hospital admissions per-person, with a ten percent drop over the last 14 years reported. This again occurred despite a four year increase in the province's median age over that period. 

Ontario hospital admissions decline sharply

There are 3.3% fewer admissions in Ontario than the rest of Canada (0.089 admissions per-capita in Ontario in 2013/14, versus 0.092 per-capita in the rest of Canada).

hospital ambulatory care visits increase

Hospital Ambulatory Care:  Ambulatory care visits to hospitals in Ontario continue to increase - -but much less quickly than in the past and less rapidly than in the rest of Canada.  

So, Ontario is experiencing both a  dramatic loss of inpatient days and a marked slowdown in the growth of ambulatory care.  Since 2011-12 there has been an actual (albeit modest) decline on a per-capita basis.

Ontario still has more ambulatory care visits than the rest of Canada – 1.4 per person in Ontario in 2013/14 versus 1.24 per person in the rest of Canada. However, in 1999/2000 Ontario had 25% more ambulatory care visits per-capita than the rest of Canada, while now the gap is about half that (12.7%).  So the gap is shrinking quickly. 

hospital ambulatory care visits in Ontario and Canada

This fits with the slowing growth  of ambulatory care in Ontario. On a per person basis, there has been very little growth in ambulatory care visits since 2005-6 in Ontario -- 3.7% (compared to 10.7% growth in the rest of Canada).  As noted, Ontario has actually seen a modest decline in ambulatory care visits per-capita since 2011-12 (from 1.43 to 1.38 per person). 

In sum:
  • In key ways, hospitals provide fewer services in Ontario than in the rest of Canada.
  • Ontario provides far fewer hospital inpatient days compared to the rest of Canada
  • Inpatient days in Ontario are now falling even while they continue to increase in the rest of Canada.
  • The loss of inpatient days in Ontario has increased since government funding cutbacks started at the end of the last decade.
  • Ontario hospitals do provide somewhat more ambulatory care than in the rest of Canada and the amount of ambulatory care in Ontario has increased over the last 14 years.  
  • The growth of ambulatory care however is slowing in Ontario and has recently come to a halt on a per-capita basis. Across Canada, it continues to grow and the gap in ambulatory care between the rest of Canada and Ontario has shrunk markedly.
  • Despite fewer hospital inpatient days to treat patients, more and more patients are showing up at Ontario ER rooms (6.7% more ER visits and 13.4% fewer inpatient days over the last four years). 
  • Emergency rooms are used much less in Ontario than in the rest of Canada.
  • While inpatient admissions are somewhat lower in Ontario than the rest of Canada the gap is not so large as with inpatient days. Accordingly patients must be released more quickly in Ontario than the rest of Canada.
The years 2014/15 and 2015/16 saw real hospital funding cuts in Ontario so it will be interesting to see how they impact hospital service numbers when they are available. 

The data is reported below. 


Public sector employment in Ontario is far below the rest of Canada

The suggestion that Ontario has a deficit because its public sector is too large does not bear scrutiny. Consider the following. 

Public sector employment has fallen in the last three quarters in Ontario.  Since 2011, public sector employment has been pretty flat, with employment up less than 4 tenths of one percent in the first half of 2015 compared with the first half of 2011.

2011-2015 public sector employment

This contrasts with public sector employment outside of Ontario which has gone up pretty consistently and is now 4.7% higher than it was in the first half of 2011.

Public sector employment 2011-2015

Private sector employment has also gone up consistently over that period. In Ontario, it has increased 4.3% since the first half of 2011, while in Canada as a whole it has increased 4.9%.

Private sector employment 2011-2015

Private sector employment in Canada 2011-2015

Public sector employment as percent 2011-2015

As a result, public sector employment in Ontario is now shrinking as a percentage of the private sector workforce.  In contrast, in the rest of Canada, it is increasing. Moreover, public sector employment is much higher in the rest of Canada than in Ontario.  Indeed as a percentage of private sector employment it is now almost 5 percentage points higher in the rest of Canada than it is in Ontario.  
Public sector employment Canada excluding Ontario 2011-2015 

Further, as a percentage of the population, public sector workers in Ontario fall well below the corresponding percentage for the rest of Canada.  

Public sector workers as percent of population 2010-2015

Indeed, private sector workers are a larger percentage of the population in Ontario than the rest of Canada.

Private sector workers as a % of population -- 2010 to 2015
If Ontario was like the rest of Canada, we would have 117,000 more public employees and 121,000 fewer private sector workers.  This despite having the capital of Canada in Ontario.

As noted last July, low revenue, not bloated public spending, drives the deficit in Ontario.  

Health care and social assistance workers: There has been a larger increase in “health care and social assistance employees” than for either public sector workers or private sector workers over the last five years according to Labour Force Survey data from Statistics Canada. 

In Ontario, the 11% increase from 2010 to 2015 is about twice the rate of increase of public sector and private sector workers (which increased 6.1% and 5.1% respectively over that period).  Given an aging population and increasing demand for health care utilization, rapid increases may well continue  -- but whether this drives up private sector health care workers or public sector health care workers is another matter. More on this in an upcoming post.

Health care employees 2010-2015

Notably, Ontario has both a lower level of health care and social assistance workers than the rest of Canada (relative to population), and the rate of increase in the number of health care and social assistance workers has been almost 1/3 faster in the rest of Canada than in Ontario.

Health care employees chart -- Ontario -- 2010-2015

More detail on the nature of the changes to the health care workforce will come in a future post.  

Data Sources: Statistics Canada CANSIM 282-0089 and CANSIM 282-0088


Hospital worker sick leave: too much or too little?

Ontario hospital workers are much less absent due to illness or disability than hospital workers Canada-wide.  In 2014, Ontario hospital workers were absent 10.2 days due to illness or disability, 2.9 days less than the Canada wide average – i.e. 22% less.  In fact, Ontario hospital workers have had consistently fewer sick days for years.

This is also true if absences due to family or personal responsibilities are included.

Statistics Canada data for the last fifteen years for Canada and Ontario are reported in the chart below, showing Ontario hospital workers are consistently off work less.

Assuming, Ontario accounts for about 38% of the Canada-wide hospital workforce, these figures suggest that the days lost due to illness of injury in Canada excluding Ontario are about 13.6 days per year ([13.6 x 0.68] + [10.2 x 0.38] = 13.1).

In other words, hospital workers in the rest of Canada are absent from work due to illness or disability 1/3 more than Ontario hospital workers. 

In fact, Canadian public sector workers and Canadian unionized workers are off sick about one quarter more than Ontario hospital workers (see chart below for absences for Canadian public sector and unionized workers). 

Obviously, hospital workers should not be working with sick patients if they themselves are sick. The much lower absence from work in Ontario hospitals raises some questions if the crack downs on sick leave by Ontario hospitals have gone too far.

Absences due to workplace injuries

Workplace Safety and Insurance Board (WSIB) provides data on Schedule 1 employers (i.e. those that are insured through WSIB and are not self-insured). Covered hospital employees have increased over the last 12 reported years, increasing from 176,000 to 205,000 covered employees (a 16.5% increase).

Over that time, despite the significant increase in covered employment, the number of allowed lost time claims has decreased from 3,379 in 2002 to 2,145 in 2013 ― that is a 63% drop. The decline in the number of allowed lost time claims began in about 2010 and has accelerated since then.

Interestingly, the lost time injury rates have declined for all industries over this period ― even more sharply. Hospital workers have gone from a little under the all-industry average to somewhat over the all-industry average. Notably, the injury rate in nursing homes is much higher, although it too is declining.

Hospitals have declined from a rate of 1.92 to a rate of 1.05, while all industries have declined from 2.10 to 0.95.
  In other words, hospitals had an injury rate that was 91.4% of all industries, and they now have an injury rate of 110.5% of the all industries rate.  

Meanwhile, workers in long term care facilities in Ontario have a sky high lost time injury rate - more than double the hospital rate and almost two and a half times the all industry rate.  Long Term Care workers and community members have been campaigning for years for more staffing time ("Time to Care"). Almost certainly, the hectic rush of long term care work contributes significantly to the very high lost time injury rate in that industry.  

Public sector and private sector absences 

Occasionally, public sector workers, like hospital employees, are attacked for the amount of absences relative to private sector workers.  A recent Statistics Canada report (“Understanding public–private sector differences in work absences”) reviews public sector ― private sector differences in leave due to illness, disability, or family and personal responsibilities, and sheds some light on these claims.

The report concludes that absences from work have remained ‘relatively stable in recent years’.
Average days lost per worker per year across several characteristics, 1997, 2011 and 2012

Both sexes
Age group

15 to 19
20 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 and over
Note F:
Union coverage

Union member or covered by collective agreement

Note F:  too unreliable to be published
Note:  Other personal and job characteristics are available in CANSIM tables 279-0029 to 279-0039Source:  Statistics Canada, Labour Force Survey, 1997, 2011 and 2012.

The Statistics Canada study does note that there is a significant difference between public sector and private sector absences from work.  In 2012, full-time workers in the private sector took 8.3 days off on average (6.7 for illness or disability plus 1.5 for personal or family responsibilities).  In contrast, full-time workers in the public sector took 12.4 days (10.5 days for illness or disability and 2.0 days for personal or family responsibilities).

However, the Statistics Canada report found that this was largely due to differences in the unionization, age, and gender of public sector and private sector workers.

Women workers, older workers, and unionized workers tend to have more absences (see chart on left) and women workers, older workers, and especially unionized workers are more commonly found in the public sector than the private sector.  (The study suggests that women have more absences as they have more family responsibilities and that older workers have more illness.  Presumably unionized workers have more absences because they are much more highly unionized and have bargained superior sick and family leave provisions.) 

Unionization alone accounts for over half (55%) of the difference in absence from work between the private sector and the public sector.  Indeed, unionized workers as a whole had more days absent in 2012 than public sector workers.


The growing role of Practical Nurses

New Canadian Institute for Health Information (CIHI)  data  paints a picture of rapid change in nursing in Ontario, especially for Practical Nurses (called "RPNs" in Ontario and "LPNs" elsewhere).  Here is a summary of the most interesting data from those charts concerning Ontario.

The number of full time RPNs and LPNs is rapidly increasing  Note:
    Last ten years has seen a rapid increase in practical nurses
  • The rapid increase in the Ontario RPN workforce (52.3% increase since 2005, and 5.6% in 2014)
    Practical Nurses are catching up to Registered Nurses
  • The rapidly increasing ratio of RPNs to RNs: Working RPNs are now at 38.1% of the number of working RNs in Ontario, up from only 27.3% only a decade ago
  • While growth is much less marked, the RN workforce does continue to increase in Ontario – 9.2% since 2005 and 1.6% in 2014 alone
  • The very rapid increase in RPNs who graduated from college within the last ten years
  • The declining average age of RPNs and the increasing age of RNs
  • The percentage of “full time” employment (as defined by the employer) increased for RNs but was fairly flat for RPNs over 2005-2014.  (That said, given the large increase in the number of working RPNs, the absolute number of full time RPNs increased significantly.)

Practical Nurses (LPN . RPN) numbers by type of employer Canada and Ontario
Hospitals remain the largest employer of RPNs in Ontario, but only just, as LTC facilities now employ almost as many now.  If present trends continue, LTC will soon become the biggest employer of RPNs.  

Notably, across Canada, hospitals employ a bigger percentage of all practical nurses than hospitals in Ontario do,  with hospitals employing 48.9% of the total number of practical nurses across Canada versus just 40.9% of the total number of practical nurses in Ontario.  

This is a major change -- in 2005 Ontario hospitals employed 48.7% of the total number of Practical Nurses in the province, while across Canada, hospitals employed just 47.5%. 

Ontario hospitals now lag hospitals in other provinces in terms of Practical Nurse employment. 

Currently, Ontario has 1.11 practical nurses working in hospitals per 1000 population while Canada as a whole has 1.34 practical nurses. 

In other words, Canada as a whole now has about 21% more practical nurses working in hospitals per capita than Ontario does.  There is room for growth for Practical Nurses compared to the rest of Canada. 

While hospital RPN employment is shrinking rapidly as a percentage of total RPN employment in Ontario, the number of RPNs working in Ontario hospitals is still increasing significantly -- 36% since 2005 and 2.2% since 2013.

Indeed, the ratio of RPNs to RNs in Ontario hospitals has increased significantly over the last ten years -- increasing from 19.8% to 24.7%.

Practical Nurse and Registered Nurse numbers in hospitals in Canada and Ontario

Nevertheless, this increase falls far behind the changes that have gone on in hospitals in Canada as a whole, where the ratio of Practical Nurses to RNs has increased from 19.2% to 27.4%. 

For Canada excluding Ontario, the Practical Nurse - RN ratio has increased from 18.8% to 29.0% over the same period - -increasing by more than half. Clearly, hospitals in the rest of Canada are increasing the use of Practical Nurses much more quickly than hospitals in Ontario.  

While Ontario hospital Practical Nurses are relatively sparse, the Ontario Practical Nurse workforce is only slightly below the country-wide average – 2.72 per 1000 population versus 2.76 Canada-wide.

Practical nurse care in Ontario and Canada

Long-Term Care has seen more rapid growth in Ontario RPN employment -- 72% growth since 2005 and 6% since 2013.  

In terms of type of care provided, RPNs in Ontario continue to primarily provide LTC / geriatric care (42.3%), Medical/Surgical care (10.9%), psychiatric care (7.9%), and rehabilitation (4.6%). These four categories also account for the bulk of the Practical Nurse work across Canada.  There seems to be very little role for RPNs in Ontario in home care and public health. 

(A word of caution -- there was a very large increase in the catch-all category “other direct care” in 2014 and a sharp drop in “Community Health”.  So there may be some classification issues.)

For more CIHI nursing data charts click here.  

CIHI has also released a study  on nursing that has drawn some media comment.  Legitimate comment has been made on the fact that RN supply has decreased in the last year across Canada. 

Nevertheless, RN supply has also still seen 9.2% growth since 2005. (And, as noted above, the RN workforce continues to increase in Ontario.)  

Also notable is that part of the recent decline in RN supply Canada-wide  is connected with regulatory changes introduced in Ontario that resulted in 12,273 nurses leaving the profession: “In 2014, the College of Nurses of Ontario introduced the Declaration of Practice requirement whereby a member can renew only if she or he has practised nursing in Ontario within the past 3 years or has become registered or reinstated within the past 3 years. If these conditions are not met, the member has the option to move to the non-practising class, resign her or his membership or do nothing and have her or his membership revoked.”

Nurse supply 2005-2014

The study also indicates the supply of Practical Nurses (LPNs, or, in Ontario, RPNs) continues to increase across Canada, albeit not quite as rapidly as over the last decade.  LPN supply is now 49% higher than in 2005.   (Note “RPN” for CIHI -- and in the graph above-- means Registered Psychiatric Nurse.)

Employed Nurses:  The CIHI study notes that from 2005 to 2014, the proportion of nurses “not employed” declined among RNs and Nurse Practitioners  from 5.2% to 2.2%.  This is perhaps not surprising given the recent decline in supply of RNs.  Despite the very rapid growth in LPN supply, LPNs “not employed” also declined (7.5% to 4.9%).

Rates of "full time employment" (as defined by the employer) for Practical Nurses lag RN and Nurse Pactitioner full time employment (48.5% for LPNs versus 58.5% for RNs / NPs).

Practical Nurses younger than 40 outnumbered those age 60 and older by more than 6 to 1. For RNs/NPs, the equivalent ratio was 3 to 1. This younger age profile for LPNs is not surprising given the rapid growth in LPN supply over the last decade.  

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