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)   .  Here is a summary of the most interesting data from those charts concerning Ontario.

  • The rapid increase in the Ontario RPN workforce (52.3% increase since 2005, and 5.6% in 2014)
  • 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.)

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 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.

I perhaps should add that 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.

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.”

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.  


Lowest health care funding increase ever?

Funding increase hits new low: The Ontario government plans health sector spending growth of 1.2% this year compared with the interim spending estimate for 2014/15.   This deepens the trend to cut health care funding increases.

Actual 2013–14
Interim 2014–15
Plan 2015–16
Health and Long-Term Care
% Increase

The average increase over the last four years is 2.2%.  Over the previous six years, funding increases averaged 5.9%, well more than double the more recent average.  This year's plan of 1.2% is a new low. 

In 2011, the then Auditor General noted that various factors (inflation, aging, population growth, and increased utilization) created health care cost pressures:  “The government’s 2005 projection was that, over the long term, these factors would drive up health-care costs by 5.9% annually, while more recent estimates indicate that these factors will result in annual increases in the 6%–7% range.”  

Declining share of the economy: As a percentage of the economy (Gross Domestic Product) Ontario government health care spending has declined consistently since 2009-10, when it is was at 7.23% of GDP.  Last year it was at 6.96%, and this year it is planned to be at 6.76%.  As a percentage of total government expense, health care spending will fall from 38.8% last year to 38.5% this year. 

The current Budget plan is to increase health care spending to $51.7 billion in 2016/17 (a 1.8% increase) and $52.7 billion in 2017/18 (a 1.9% increase). With nominal GDP expected to go up at more than twice that rate (4.2% for both years), health care spending would continue to decline as a percentage of the economy. 

Less than Drummond:  If these increases are implemented, the increases for 2015/16 through 2017/18 would average 1.63% -- about a third less than even the 2.5% annual increase for health care recommended by the 2012 Drummond Report.  This year's proposed increase is half of the rate proposed by Drummond.   

At the time Drummond characterized his cuts as "a wrenching reduction from the path that spending is now on."   Drummond claimed that no jurisdiction had limited health care funding to his planned 2.5% increase in the last thirty years. 

The health care sub-sectors: Below the level of government ministries, the Budget gets quite vague. Bearing that in mind, however, the figures that are supplied for the health care sub-sectors are of some interest, at least as a broad estimate. 

Provincial hospital funding: The stated policy of the provincial government is to move funding out of hospitals and into other health care sub-sectors.  We are now in the fourth year of a freeze on funding for base hospital services. There has been some other funding for growing parts of the province:  this year, for example, total hospital funding is supposed to go up 1.4%. 

Planned hospital expense increases have slowed almost to a stop.  Over the last four years, planned increases have averaged 1.275%.  Over the previous six years, planned increases averaged 4.8%, almost 4 times the more recent average.

Planned hospital funding has also declined as a percentage of total health care funding under the Liberals, declining from 46.4% of health care funding in 2010-11 to 43.7% in 2015-16.   

Planned hospital funding increases over the last four years have not increased at the rate of inflation, never mind cost pressures arising from population growth (about 1% per year) aging (about 1% per year) and utilization demands.  The discrepancy will have to be made up by extraordinary productivity increases or, more likely, by cuts to utilization and quality.

Long-term care: The 2015 Budget documents actually suggests there will be fewer long-term care beds than estimated in the last two Budgets, bringing the number down by 400 beds to 77,600.  According to Budget estimates, we have had a 2.8% increase in the number of LTC beds since 2006 Budget  -- despite much larger growth in the relevant population (i.e. those 85+).   Getting into an LTC bed is getting harder -- and those that do get in will need more care. Whether they get it is another question.

The Budget figures suggest otherwise -- 1.9% increase per bed, with funding reaching $51,000 per bed. That just about keeps up with inflation.   When you consider the reduced number of LTC beds, the total planned increase for LTC is only 1.4%  -- about the same increase as planned for the hospital sector.

Total LTC funding is supposed to reach just under $4 billion.  

Home and Community Care: Part of this sector at least is supposed to do somewhat better, with the Budget claiming that homemaking and support services will go up to 26 million hours from the 24 million hours estimated in the 2014 Budget. That is a significant increase -- roughly 8%.   

Funding, however, will only go up at about half that rate, increasing from $750 million in the 2014 Budget to $780 million in the 2015 Budget estimate.  How the government plans to increase service by double the increase in funding is a good question - - a  very good question.   On these figures, the cost per hour of service is $30 overall.  The cost of this year's added 2 million hours of service, however, is $15 per hour (2 million added hours for an extra $30 million).  That's quite a price drop. Especially as the government has promise to raise PSW wages significantly.  

Nursing and professional services did not do so well -- despite the new claims today from the Ministry of Health and LTC.  Nursing and professional home care services are supposed to remain at 7 million visits, the same as estimated in the 2014 Budget.  

Notably, this is down 1 million visits from the estimate in the 2010 Budget, the 2011 Budget, and the 2013 Budget -- all of which estimated 8 million nursing and professional home visits.  

This puts in perspective, perhaps, today's headline claim from the Ministry of Health and LTC that they will increase nursing care by 80,000 hours -- through an extra $5 million in funding. That's about a 1% increase -- so it might just keep up with population growth but it is not going to offset growing demand arising from an aging population, never mind offset cuts in hospital and long term care.  Moreover, they are still going to be well short of the service level they claimed a few years ago.

Funding for  nursing and professional visits is supposed to increase this year to $550 million from the $530 million estimated in last year's Budget.  On these estimates, the cost per visit is now, very roughly, in the range of $78.50


Collective bargaining in Ontario: New trends, new possibilities

New possibilities for collective bargaining in Ontario
New militancy: Recent strikes in the broader provincial public sector by 13,000 university teaching assistants and Community Care Access Centre employees (mostly RNs) suggest increased willingness of some broader public sector employees to strike to maintain and improve their working conditions.  Moreover the workers achieved some success in their strikes.  In the health care sector, the Health Minister, Eric Hoskins, felt it necessary to publicly call for the negotiations to be settled by interest arbitration.  Shortly after this, a leading arbitrator awarded both of the proposals (wage proposals) demanded by the union.

Both of the recent Teaching Assistant strikes at York and the University of Toronto put paid to the government's idea of "net zero" compensation increases, at least in the university sector, as the strikes made progress for those workers. Provincially coordinated teacher strikes are now underway to deal with the government's demands as well.  

Clearly there is now more appetite among public sector workers to change the bargaining climate.  Essential service workers (like hospital workers) can only benefit from this as interest arbitration (the method for resolving contract disputes for essential service workers who are not allowed to strike) follows established trends among comparable workers.

That said, the bargaining climate for provincial public sector workers remains challenging. 

Recent Bargaining Trends: Provincial broader public sector settlements averaged 1.3% in 2014, a significant improvement over 2013.  Nevertheless, they are lower than private sector settlements for the fifth year in a row, as private sector settlements averaged 1.8% in 2014, half a percent higher.

On an annual basis, private sector settlements have averaged 1.84% since 2010, while broader provincial public sector settlements have averaged 1.20%.  That means private sector settlements have averaged 0.64% more per year.

Federal public sector settlements have done better than provincial broader public sector settlements, but worse than municipal settlements and private sector settlements, with an annual average of 1.68% since 2010.  Stephen Harper has increased public sector wages more than the Ontario Liberals.  Even so, in 2014, federal settlements have averaged 1.5%, very similar to Ontario provincial broader public sector and municipal settlements. 

Broader provincial public sector settlements have fallen behind the annual inflation rate for the fifth year in a row.  Here the gap is larger, with Ontario inflation averaging 2.08% annually for 2010 through 2014.  That contrasts to the average annual provincial public sector wage settlement of 1.20%. 

In other words provincial public sector settlements have, on average, trailed the annual inflation rate by 0.88% each year for the last five years. That is a shortfall of almost 1% per year for five years ― quite a gap. 

This, of course, flies in the face of those who would like to portray provincial public sector workers as receiving rich settlements.  The reality for the last five years is that broader provincial public sector settlements have fallen well short of the annual inflation rate and that private sector settlements have been significantly higher. 

Municipal public sector settlements: Municipal unions have done a little better ― averaging 2% per year from 2010 through 2014 (although this is still short of the inflation average).  Municipal government settlements with police and fire have played a role here.  

Also notable ― the advantage of municipal settlements over provincial broader public sector settlements is at the lowest level since 2010:  municipal settlements in 2014 averaged 1.7%, only 0.4% higher than broader provincial public sector settlements.  In 2013, the gap was a huge 1.9%, as provincial public sector wage settlements hit a low point.  

2015: With settlement data only available for January and February, the general trend of 2014 continues: broader provincial public sector settlements have an average annual wage increase of 1.3%, municipal settlements average 1.7% and private sector settlements average 1.8%. Notably, the latter two are, at least, above the bank-predicted rate of inflation for 2015 (of 1.3%)  -- even if well short of the predicted rate for 2016 (2.4%). 

Government's bargaining position: The government's position in the 2015 Budget regarding the 787,000 workers in the "broader provincial public sector" (i.e. broader public sector workers excluding federal and municipal government employees) is as follows:  
Compensation costs must be addressed within Ontario’s existing fiscal framework, which does not include additional funding for wage increases. Any modest wage increases must be offset by other measures to create a net zero agreement, and all public-sector partners must continue to work together to control current and future compensation costs.  (My emphasis --DA.)
Just after this, however, the Budget brags that the government will have reduced pension expense for public sector workers by $2.3 billion per year by 2017/18, for a cumulative savings of $6 billion over the five years since 2012/13:  
In 2012, the Commission on the Reform of Ontario’s Public Services forecast that pension expense would increase by $1.1 billion over the period from 2012–13 to 2017–18. The current government forecast of pension expense projects a decline of $2.3 billion over the same period, resulting in a cumulative reduction of $10.3 billion compared to the Commission’s forecast. This represents a further improvement from the 2014 government forecast, which projected a decline of $1.5 billion over the same period and a cumulative reduction of $8.7 billion compared to the Commission’s forecast.

TABLE 2.1 Difference in Projected Pension Expense versus Commission on the Reform of Ontario's Public Services' Forecast
($ Billions)
Commission Report3.
Current Forecast3.
Difference in Forecast(0.1)(0.8)(1.2)(1.9)(2.8)(3.5)
Source: Ontario Treasury Board Secretariat.
The Drummond Commission used "pension expense" to suggest public sector pension expenses were rising too quickly, although the connection of pension expense to the actual cash cost of the pension is shaky.   The government's response was to all but require public sector employer contribution caps for five years.   

These pension expense "savings" just keep on getting bigger and bigger:  
  • In the 2013 Budget, they estimated a total savings of $2.1 billion from 2013/14 through 2017/18 (and $600 million this fiscal year alone).  
  • In the 2014 Budget, they estimated a savings of $4.3 billion from 2013/14 through 2017/18 (and $1 billion this fiscal year alone).  
  • Now in 2015, they estimate a total savings of $6 billion from 2013/14 through 2017/18 (and $1.2 billion this fiscal year alone).  
Elsewhere in the 2015 Budget, the government also suggests major savings for single employer public sector pension expenses.  

Decline in pension expense opens possibilities in Ontario collective bargaining

The results of five years of struggle:  Predictably, during the recession private sector workers took it on the chin, before recovering to a better bargaining position.  But, also predictably, a year after the recession had ended, the province started to use the recession and the new provincial deficit as an excuse to go after public sector workers.  

In the summer of 2010, the provincial government required unions to consult extensively with them on their goal of zero wage increases for two years. The unions, by and large, did not agree to those terms.  The Dalton McGuinty government stepped up its campaign in 2012 by demanding wage freezes, concessions, and then implemented legislation attacking free collective bargaining when public sector workers did not agree to those terms.  

This dramatic step up in their demands was political not fiscal.  In 2010, when the McGuinty government started its campaign for a wage freeze in the provincial public sector, citing the state of the public books.  At that time they had estimated deficits totaling $74.2 billion from 2009/10-2012/13.

Deficit (in billions of dollars)
2010 Budget
2013 January
Reduction in Deficit

However, these proved utterly unrealistic ― the real deficits by early 2013 were actually $16 billion less.

Despite the decline in the deficits, by the summer of 2012 the government increased their demands on broader public sector workers.  A wage freeze would no longer do ― now it had to be a wage freeze plus significant financial concessions (e.g. cuts to sick leave and retirement pay-outs).  The government claimed that their plan would save $8.8 billion over three years ― i.e. much less than what they had already paired from the deficits since they started their wage freeze campaign in 2010.

The government was quite prepared to attack free collective bargaining to get the concessions they desired, despite the fact that major unions opened bargaining with a proposal for a wage freeze ― a freeze which would have accounted for much of the government's savings goal.

But, fortunately, this new approach led to some significant, if very uneven, fight backs by working people that undermined the McGuinty government’s claim that it offered something different from the public sector union bashing of the previous Progressive Conservative government.  The popularity of the McGuinty government declined dramatically (aided by the privatized P3 gas plant scandal) and both McGuinty and Finance Minister Dwight Duncan quickly announced their resignations.

The new premier, Kathleen Wynne, kept the goal of zero compensation increases in the provincial public sector, but reduced the emphasis on concession demands and abandoned -- or at least temporarily moved away from -- the threat of legislative attacks on collective bargaining in the public sector. Whether the government sticks to the principles of free collective bargaining we shall soon see as the teacher strikes unfold.

Broader public sector wage settlements within the provincial government’s domain (i.e. public sector settlements excluding federal and municipal settlements) have significantly increased since 2013’s stingy 0.3% average annual settlement.  

But if they continue to improve will depend on the current struggle. Employers and right wingers saw the recession as a opportunity to set back unions -- and achieved some results (from their point of view). But the recent struggles by public sector workers suggests that their gains may only be short term -- the attacks have, in some cases, led to stronger public sector unions.


Ontario's economy improves. Will collective bargaining follow?

The Ontario Economy:  The 2015 Ontario Budget has revised the government's real growth estimate up significantly from its 2014 Fall Economic Fiscal Outlook.  Real growth for 2014 is now put at 2.2% for 2014, up from the fall forecast of 1.9% and real growth for 2015 is forecast at 2.7%, up from their fall forecast of 2.4%.  Both of these forecasts are slightly lower than the forecasts from the banks and other private sector forecasters. 

With lower oil prices and a lower dollar, Ontario is now growing faster than the rest of Canada.

Substantial Real Growth -- but who benefits?  Seven years ago (starting the latter half of 2008) there was a recession in Ontario.  It ended six years ago when economic growth began again in the third quarter of 2009 (i.e. July-Sept 2009).  Since that time there has been significant economic growth, placing the Ontario economy well above its pre-recession high.  

Ontario, Gross Domestic Product (GDP)

($ Billions)

Real GDP (chained $2007)
Nominal GDP
Real GDP increased $34.6 billion (in constant 2007 dollars) by 2013 compared with the pre-recession high in 2007.  That is a 5.78% real increase over the previous high point.  

The new provincial Budget forecasts another 7.5% real growth for 2014 through 2016.  Private sector forecasts are slightly higher.  While (as the next blog post will demonstrate) workers have not benefited from this real growth, some others must have done very well indeed

Nominal GDP (real growth plus inflation) has increased even more significantly, increasing $97.9 billion dollars between 2007 and 2013, a 16.4% increase.  The provincial Budget forecasts another 12.5% nominal growth for 2014 through 2016.

Thirty percent growth in nominal GDP is significant for at least two reasons.  First wages are paid in nominal dollars: they are not automatically adjusted for real growth or inflation.  To maintain their relative share of the real economy and to protect against inflation, compensation must be adjusted.

Second, nominal GDP growth is the key driver of government revenue increases. As it increases, so do government coffers, increasing the government's ability to spend. 

Unemployment falling: Given significant real economic growth, the Ontario unemployment rate has declined.

Source: Statistics Canada CANSIM Table 282-0087 http://www5.statcan.gc.ca/cansim/a47

For the first two months of 2015, the Ontario unemployment rate was reported at 6.9% by Statistics Canada. The provincial Budget forecasts that it will hit 6.3% in 2018.  

Ontario consumer inflation is predicted to dip in 2015 but return to the 2.3% range in 2016, with the bank estimates averaging 2% per year over 2014-2016.

Royal Bank2.21.42.2
Bank Average2.271.32.37

Federal Transfers to the provincial government are also driving up revenue: The recently announced major federal government transfer payments to Ontario for 2015/16 (for equalization, health and social transfers) are also much higher than expected.  In fact, about $450 million more than the $800 million increase the provincial government anticipated for all federal transfers to the province.  (Stephen Harper is, after all, facing an election this fall.) 

In total Ontario will receive $1.253 billion extra ― or 6.5% more than the federal transfers to the Ontario government for 2014/15. That, just in itself, is equal to a 1.1% increase in program spending.

The bulk of these increases are for health care. The federal health transfer to the province is up $735 million for 2015/16.

Federal Support to Ontario (millions of dollars)
Canada Health Transfer
Canada Social Transfer
Total - Federal Support
Per Capita Allocation (dollars)
Source: Canadian government, Dept. of Finance:  http://www.fin.gc.ca/fedprov/mtp-eng.asp#notes

Planned provincial spending falls flat:  The 2014 Budget planned total spending at $130.4 billion.  This year's Budget plans total spending of $131.9 billion, an increase of $1.5 billion -- or 1.1%. Notably, the provincial government is actually budgeting less for 2015/16 than they said they would budget for 2015/16 in the 2014 Budget -- $200 million less.

Moreover, almost all of the new spending planned by the provincial government is actually just increased transfers from the federal government -- 83% of the total planned increase comes from increased major federal government transfers to the Ontario government ($1.25 billion out of a total increase of $1.5 billion).  

As the government generally spends less than the planned figure set out in the Budget, it is very possible that all of the actual increased spending at the end of the year will be from federal transfers.

For health care, the situation is more extreme. Health care was budgeted at $50.055 billion in the 2014 Budget.  It is now budgeted at $50.8 billion for 2015, an increase of $745 million (or 1.5%). In other words, the Ontario government is planning to increase health care spending by less than the $753 million increase in federal transfers for health care.

The Ontario government is providing fewer new dollars for health care from its own sources than last year.

(Note: the percentage increases noted here are a little different than some other commentators.  Here, I have compared figures in this year's Budget to the figures in last year's Budget and not to the interim figures for last year in this year's Budget.  As the government typically under spends their Budget, comparing this year's budgeted figures with the interim figures for last year reported in this year's Budget will likely exaggerate the rate of increase. Better to compare figures set at the same time in the respective fiscal years to get comparable figures.)

The Province’s Fiscal Situation: The provincial deficit has been used as a powerful tool to justify attacks on public sector collective agreements, with the government falling into significant deficit during the last recession in 2008/2009.

So it is notable that the Ministry of Finance has once again reduced its estimate of the provincial deficit, lopping $1.6 billion off its estimate of the 2014-15 deficit in late March bringing it down to $10.9 billion. Based on past experience and the improving economy, a further reduction may occur when the government finalizes its 2014/15 deficit with the Public Accounts in the early fall of 2015.  (Last year's Public Accounts took another $800 million off the deficit compared to what the government stated it was in last year's Budget, so a further cut may be coming this year too.)

The 2015 provincial Budget forecast a deficit of $8.5 billion for 2015-16.  This is $400 million less than forecast for 2015-16 in the 2014 Budget.   Roughly $200 million of this is due to the fact that the government now plans to spend less than it planned in the last Budget. 

The consistent pattern for this government has been to make Budget forecasts that overestimate the deficit.  On average they have overestimated the deficit by 31% for each year since the 2009 Budget.

Based on past experienced, the $8.5 billion deficit for this year may well be overstated too.

Upcoming on April 30: Collective Bargaining Settlement Trends: New Possibilities?

Photos: Kat R Canadian Money

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