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.  


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

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