Ontario long-term care staffing falls far short of other provinces

CUPE and others are campaigning for a legislated minimum average of four worked hours of nursing and personal care per resident per day in long-term care (LTC) facilities.  New research indicates that not only is LTC underfunded in Ontario, it is also understaffed compared to the other provinces. 

LTC staffing falls short:  The latest data published by the Canadian Institute for Health Information (and based on a mandatory survey undertaken by Statistics Canada) indicates that staffing at long-term care (LTC) facilities falls far short of other provinces. 

Part of this is driven by a low level of provincial funding for LTC.

Ontario has 0.575 health care full-time equivalent employees (FTEs) per bed staffed and in operation.[1]  The rest of Canada reports 0.665 health care FTEs.[2]  The rest of Canada has 15.7% more health care staff per bed staffed and in operation than Ontario.[3] 

No other province reports fewer LTC health care staff per resident (or per bed) than Ontario.[4]

Occupancy rates are slightly higher in Ontario than in the rest of Canada (97.4% in Ontario versus approximately 96.8% in the rest of Canada).  As a result, there are
0.590 health care FTEs per resident in Ontario and 0.687 in the rest of Canada.
Ontario:  (0.575*100/97.4) = 0.590
Rest of Canada:  (0.665*100/96.8) = 0.687

This is equal to 3.15 paid hours per day in Ontario and 3.67 hours in the rest of Canada.
Ontario: (0.590*1950 hours) / 365 days = 3.15 hours per day
Rest of Canada: (0.687*1950 hours) / 365 days = 3.67 hours per day

This means the rest of Canada has 16.4% more health care full-time equivalent staff per LTC resident than Ontario.  That is over half an hour of extra paid care for every resident on every day.

Other LTC Staff:  This gap is not made up by more of other sorts of staff.  In Ontario, there are 0.220 FTEs per bed in non ‘health care’ occupations (i.e. “administration and support”: dietary, housekeeping/laundry, administration, maintenance, plant, security, and other general services).  But in the rest of Canada there are 0.276 FTEs per bed.  In other words, there are 25.5% more administration and support employees per bed in the rest of Canada than in Ontario.

In total, there are 0.931 FTE staff per bed staffed and in operation in the rest of Canada but only 0.794 in Ontario.  Per resident the ratio is 0.962 staff in the rest of Canada compared to 0.815 in Ontario.

Another way of putting this is that there are 18% more paid staffing hours per resident in the rest of Canada than in Ontario.  That is 47 more minutes of paid care and service for each resident every day than in Ontario. 

Conclusion:  Care in long-term care facilities across the country falls short of what is required.  However, care in Ontario facilities is lower than anywhere else across Canada.  Stronger staffing levels are required.  Residents in long-term care facilities are becoming sicker and so low levels of staffing is becoming a bigger problem.  

The low level of provincial funding and staffing of LTC facilities is consistent with the low level of funding and staffing of Ontario hospitals demonstrated in reports from the Ontario Council of Hospital Unions / CUPE, the Ontario Health Coalition, and others.

The latest CIHI data on LTC staffing is available by clicking here.  The CIHI data on LTC occupancy rates is available by clicking here.

[1] Notably, this is lower than reported for 2012 – which showed 0.598 FTEs per staffed and operational bed.
[2] CIHI defines a FTE as total paid hours per year divided by 1,950 hours.  For the CIHI numbers, see the links above.  
[3] Quebec is not included in the CIHI data.   The CIHI “health care staff” category includes somewhat more staff than included in the proposal for 4 hours worked care put forward by CUPE and others.   While the bulk of staffing hours fall within the CUPE proposal (RN, RPN, and PSW) the CIHI health care category also includes a few other staff - -physiotherapists, occupational therapists, recreation staff, etc.  The CIHI figures also report ‘paid hours’ rather than “worked hours”.   CUPE however focuses on the latter as it more directly measures the actual amount of care provided to residents. We estimate that worked hours equal roughly 88% of paid hours. Also note: the most recent year reported by CIHI is for the 2013 fiscal year. 
[4] BC is however close – with 0.596 health care FTEs per resident.


Hospitals rely on private sector funding more and more

The Canadian Institute for Health Information (CIHI) reports that total expenditures on Ontario hospitals increased to $23.7 billion in 2016.

This is an increase of 2.4% since 2015 and 6.1% since the 2012. While provincial government expenditures increased 4.7% over the four years between 2012 and 2016, private sector expenditures on hospitals increased at a much faster rate -- 15.8%That is more than three times the percentage increase of the provincial government increases. 

Private sector expenditures increased $124.9 million in 2016 to $3.62 billion.  That was a typical increase. The four year private sector increase was $493.1 million, averaging $123.3 million per year.  

That's  a lot more than chump change. Key types of private sector payments to hospitals are payments by private insurance companies and out-of pocket payments by individuals. 

Hospitals are now relying significantly more on private sector funds.  In 2012 private sector expenditures accounted for 13.99% of total expenditures on hospitals but by 2016 they accounted for 15.27%.  

Looking deeper, this in fact continues a decades long trend of an increasing portion of expenditures on hospitals coming from the private sector.

In 1975 just 6.17% of expenditures on hospitals came from the private sector.  But this has continuously increased:

• 10.57% in 1985
• 11.95% in 1995
• 13.34% in 2005
• 13.99% in 2011
• 15.09% in 2015
• 15.27% in 2016

The average increase in private sector expenditure on hospitals since 1975 has been 8.9%  compared with a total average expenditure increase on hospitals of 6.4%.  Over the last 41 years, private sector percentage increases have averaged almost one-third more than public sector expenditure increases. 
Private sector payments to Ontario hospitals compared to total payments to hospitals
Over the last four years, however, private sector percentage expenditure increases have been over twice as much as total expenditure increases.

Here is a comparison of the annual percentage increases for the last four years:

This is an alarming trend -- private payments are made for a purpose and that purpose is likely access to some aspect of hospital service on better terms than the general public.  

As this change is four decades long, it likely reflects some deeply entrenched trends that will not be easy to reverse, unfortunately. It certainly sounds like it fits with the squeeze of public services and the increasing inequality that has characterized developed capitalist societies since the 1970s.   

But the larger role of private sector expenditures on hospitals also indicates that provincial government or public sector expenditures no longer paint a full story of hospital funding. 

Even with provincial government (austerity) expenditure increases of only 4.7% over the last four years, total expenditures on hospitals increased 6.1% thanks entirely to a 15.8% increase in private payments.

The relevant CIHI numbers are embedded below. (For all the CIHI health care expenditure data download "data tables" on this CIHI hyperlink)


Ontario is not sinking into deficit: Better public services can be won

The Financial Accountability Office (FAO) predicts significant deficits over the next several years - despite also predicting significant economic growth. Using the government's accounting method, the FAO is predicting budget deficits of $0.5 billion this year, increasing to $3.6 billion in 2021-22. 

If the FAO is right then we do have a problem in terms of building our campaigns for better funding. Deficits will be used to clobber popular expectations for improved public services.  Already the right has taken up the FAO report to spread the deficit alarm.  

While the FAO does make some useful other points, its conclusions about the deficit are likely off base.

Revenues and Expenditures: The FAO expects tax revenue to grow 3.9% on average over the next five years, slightly below their expectations for nominal economic growth.  This is significantly better than their forecast for expenditure growth of 3.3% (which, notably, is a little below the underlying cost and demographic pressures identified of 3.6%). 

However the FAO also expects much slower growth for the second largest source of revenue, federal transfers -- 1.9% growth. 

As a result, the FAO places revenue growth at a more moderate 3.3% average over the five years -- exactly the same as their estimate for average expenditure growth. 

That sounds odd as the they expect the deficit to grow from $600 million this year (2017/18) to $3.6 billion by 2021-22.  

The base year problem: A big part of the explanation is that the base year for their five year forecast is not this year but last year, 2016/17, and they put the deficit for that year at $2.8 billion. 

So an increase to a $3.6 billion deficit after five years is in fact a modest increase in the deficit - - an increase of $800 million by 2021 -2022, or just under 0.5% of total expenditures.  On average, the deficit is expected to increase by less than 0.1% of expenditures each year for five years. 

In other words, there will be a big deficit in five years because there already is a big deficit. 

Is there really a big deficit in the base year?  The forecast deficit of $2.8 billion in the  base year of 2016/17 is itself quite odd.  It is well over a billion dollars higher than the Ministry of Finance estimated in the 2017/18 Budget.  

Key here is that the FAO estimates $1.2 billion less revenue for 2016/7 than the 2017/18 Budget estimated.  This is entirely due to a lower estimate of tax revenue by the FAO.

However, the 2017/18 Budget came out a month after the 2016/17 fiscal year ended. The finance ministry should have a pretty good estimate of revenue from the previous year one month into the next fiscal year.  They will, after all, finalize the books for that year in just a few months.  

Indeed, if past practice is any guide, this government almost always starts out with a very pessimistic assessment of the state of the deficit and then achieves a lower deficit.

Like a cautious middle manager, the government almost always initially overestimates the deficit and then in successive announcements beats its target and reports a lower deficit. Last year, for example, when they finalized the books for 2015/16 in the fall of 2016, they recognized that revenue was actually $2 billion higher than they had estimated in the 2016/17 Budget.

So the FAO forecast of a $2.8 billion deficit in the base year of 2016/17 is suspect. If past experience is any guide, it is more likely lower than the $1.5 billion the government has estimated rather than higher.  

What's the impact if the deficit in the base year is overestimated?  If the FAO's deficit in the base year is an overestimate, then what of their forecasts for the following five years? Well, Ontario will start from a much better position to avoid future deficits.

Notably, the FAO's predicted five year dollar growth in the deficit from $2.8 billion to $3.6 billion is based on the idea that a sizable deficit exists -- that expenditures in the base year were $2.8  billion more than revenues.  

Much of the predicted growth in the deficit is not because revenues are predicted to increase at a slower percentage rate than expenditures, but because the two are predicted to increase at the same percentage.     

As a result of this, the gap between the larger amount (expenditures) and the smaller (revenues) grows in dollar terms (although not in percentage terms). 

Over $500 million of the FAO's predicted $800 million increase in the deficit over five years is simply the result of the fact that both total expenditure and total revenue are supposed to increase at exactly the same percentage rate and expenditures are supposedly starting out at much higher dollar amount than revenues. 

But the math changes and the growth of the deficit is much less if the existing deficit is not as big as supposed.

(It is not clear where the FAO's other $300 million predicted growth in the deficit comes from -- rounding differences perhaps.)

The FAO Deficit Track Record: Notably, the FAO forecasting record has not been great. Well into the 2015/16 fiscal year (November 2015), they estimated the deficit for that year as between $6.8 billion and $8.5 billion.  The FAO now recognizes the deficit for that year as $3.5 billion, i.e. $3.3 billion to $5 billion less than they predicted.   

Even after 2015/16 ended the FAO was still way off.  Last year’s FAO spring economic and fiscal report (dated May 18, 2016) concluded the 2015/16 deficit would be $2.2 billion more than they now admit.  

In other words, a month and a half after the fiscal year ended, the FAO forecast the deficit as 63% higher than it was. 

If the FAO was off by that much predicting what happened the previous year, how much might they be off forecasting five years in the future?  Particularly as much of the FAO's predicted deficit five years in the future is based on the questionable notion that there already is a big deficit. 

Federal Transfers: On another related point, a big part of their modest revenue forecast is very modest  growth in federal transfers.  Part of this makes sense -- as Ontario's economy improves, federal equalization payments to Ontario will decline.  

But it is certainly worth considering that federal transfers for future years may turn out to be greater than currently announced.  The Feds don't get a lot of political credit for promising money years in the future.  They get more credit for cash that will come shortly. The federal election in 2019 may also shake some more federal cash loose (for example we won  a big increase in federal health care money from the Conservatives in the 2011 election).   As a result, the FAO's approach may inherently tend to underestimate future federal transfers.  

If the future is like the past, we will see an improved fiscal situation than predicted in the provincial Budget when the books are finalized for 2016-17 -- and not a worse situation, as predicted by the FAO.  

If that is the case, we will be in a much better situation to face the years ahead than the FAO forecasts -- even if revenue percentage increases simply match expenditure increases, as the FAO predicts

One last point: any long term forecast is dodgy, and the further into the future, the more dodgy.  Economic crisis, or revenue bonanza are hard to predict years in advance. But it is in the longer term that the FAO is more pessimistic. In the shorter term their forecast is much more optimistic.   

In  the immediate future, the FAO estimates very significant revenue growth for 2017/18 -- growth of $8.2 billion or 6.3%. That is very similar to the increase estimated by the Ministry of Finance for 2017/18 and is far above the FAO's five year forecast of only 3.3% annual revenue growth. 

This also provides some reason to think there is a little more gold to come, this year at least. 

Economic crisis will come at some point and create another crisis that will be used by our rulers to undermine public services.  

Good prospects: But barring economic crisis, discount the deficit doomsayers (they have been getting it wrong for years) and don't be discouraged. 

We remain in a good position to win better public services -- just as we did last year when the FAO (and the government) grossly overestimated the deficit.  


Hospital funding increase less than last year's

Ontario revenue and  expense projections 2017/18

In  the lead up to the Budget, the government crowed  that they had heard the public and would improve funding for hospitals. However, based on government  announcements, they actually plan to lower the hospital funding increase this year.  

They state they will increase hospital funding $518 million, a 3% increase.  But, on closer inspection, the funding increase announced for last year was significantly higher.

In the 2016 Budget, Ontario announced that it would increase hospital funding $345 million -- about a 2% increase.  Subsequently, the government announced another $140.3 million for hospital funding in the Fall Economic Statement – bringing the total increase to $485 million.   That is, of course, already quite close to the much ballyhooed hospital funding increase of $518 million for 2017/18. 

But it looks very much like the actual hospital funding increase in 2016/17 was higher than $485 million – higher in fact than the $518 million increase announced for 2017/18.

A little after announcing the $140.3 million hospital funding increase, the province, in its 3rd quarter report, announced an investment of $95.4 million to support additional capacity for stem cell transplants in Ontario.  Sunnybrook hospital will become the second hospital in the Greater Toronto Area -- along with Princess Margaret hospital-- to provide a full range of Complex Malignant Haematology, including stem cell transplants.  Apparently a very small portion of this work goes outside of the country, but most of this work is done in Ontario hospitals. 

Now, in the new Budget, the government has raised their estimate of the in-year health care spending increase from $348 million (in their 3rd quarter report) to $483 million – i.e. another $135 million increase.  The Budget describes the $483 million health care in-year increase as “primarily due to additional investments in hospitals to support the needs of patients and reduce wait times, and funding to support additional stem cell transplants in Ontario.”

So, it is likely that at least half ($242 million) of that $483 million in-year increase went to hospitals.  In total that would mean that hospitals got, at least, a $587 million increase last fiscal year ($345 M + $242 M = $587 M).

That would be $69 million more than the announced increase for 2017-18 – 13% more.   

The announced hospital funding increase for this year (3.1%) is in fact exactly half of the percentage increase announced for all other non-Ministry of Health programs (6.2%).
This all suggests that more funding has got to be announced over the course of this fiscal year if they are going to keep crisis from the door - -just like last year.

Premier Wynne told the media shortly before the Budget that she had heard the complaints about hospital funding "loudly and clearly", that she knew hospitals needed her support and  that  help would be coming. 

On Budget day, however, we got an announcement of a smaller increase than the announced increases for last year and (as discussed last week) further confirmation that they plan to decrease hospital capital funding for new hospital beds and facilities. 

Apparently, we will have to speak more loudly and clearly to be properly heard. 

P.S. - - the good news?  Hospitals in low population growth communities around the province  are beginning to report funding increases at around 2% of ministry funding for the hospital.  This tends to confirm the suggestion in the Budget that all hospitals will get at least a 2% increase in ministry funding. That is better than has been the case.  The confirmation of at least that level of funding early in the fiscal year (which began April 1) provides some basis for supporters of public hospitals to build on as the year unfolds. 


More spending on new hospitals and new beds? Nope

Hospital funding:  There is something off about the provincial government's Budget claims on hospital capital funding (funding to build and renovate hospital beds and facilities).   

For what it is worth (which is not that much, given the long time frame the government cites), the province claims it will increase hospital capital spending over the next 10 years from $11 billion to $20 billion – or on average to about $2 billion per year.  But, this is just a notional increase from the previous announcement of future hospital capital spending. 

Moreover, even if we did take this as a serious promise and not just a wisp of smoke, the government's own reports shows they have actually funded hospital infrastructure about $3 billion a year over the 2011/12-2015/16 period.

So this “increase” is really a decrease from past actual spending. Even last year's (2016-17) hospital capital funding increase was reported in this Budget at $2.3 billion - i.e. about 15% more than they have announced, on average, for the next ten years.   

Last I heard, construction costs were going up, not down, so this latest announcement means  a slower pace of hospital faciilty construction and renovation. 

Even with higher spending on hospital capital funding in the past, the Auditor General complained in late 2016 that funding was billions of dollars behind what was needed. Unless there is a significant increase, things are going to get worse.

Funding for new hospitals

Nevertheless, it is good to see that the government is at least trying to take some political credit for growing hospital beds -- see for example yesterday's Toronto Star story on new hospital beds by clicking here.  That, at least, is a little diversion from the attacks on hospitals as appropriate service providers that have characterized this government in the past.  Community and labour campaigns in favour of hospital services can take some of the credit for that.   

The alleged increased level of hospital operating funding will be discussed in the next post.

Overall health care spending will decline as a percentage of total program spending by the province this year – despite all the claims by the government that it makes health a priority, that they have heard the demands for better care, and that they are providing a "booster shot" for health care.  

Total program spending is budgeted to increase 4.9% while health care funding is budgeted to increase 2.98%.  Program spending excluding health care is budgeted to increase from $71.3 billion to $75.7 billion -- a 6.2% increase.  So health care falls a full 3.2% behind the overall program spending increase of other ministries. 

A "Health Care Budget"?  This certainly doesn't look like health care was the winner in the funding battles.

The real winners in the Budget were Advanced Education and Skills Development, Community and Social Services, Infrastructure, and, as expected, electricity cost relief, and the environment and climate change. 

Hospital and long-term Care (LTC) funding will decline as a portion of total program spending, just as overall health care funding will decline as a portion of total program spending.

Long-Term Care:  “In 2017, an additional $58 million, representing a two-per-cent increase, will be invested in resident care.”  However $58 million is not 2% of total provincial LTC funding.  That would require roughly a $66 million increase (not even counting provincial social assistance and “other” provincial funding that ends up in LTC).    

This is likely 2% of the Nursing and Personal Care (NPC) envelop and, perhaps, the Program and Support Services (PSS) envelop, the two largest portions of provincial LTC funding.   

That increase will not allow for significant increases in staffing hours for either NPC or PSS hours.  The government's refusal to open new LTC beds when the relevant population (aged 85+) is growing very rapidly means that those who get into LTC require more and more care.  

So we are stuck with another year of no more time to care while residents need more and more care. 

The third LTC envelop funded by the province, raw food, will grow by 6% -- or $15 million. “The government will increase the food allowance by over six percent this year, or $15 million, to ensure that LTC homes can provide nutritious menus that are responsive to medical and ethno-cultural needs.”   Advantage Ontario (the new name for the not-for-profit long term care providers previously named OANHSS) called for a 3.9% increase to the raw food budget - -so they (like the for-profit providers) are thrilled with this increase. How this will play on industry profits is a good question.  

These two announcements amount to a $73 million increase – very roughly a 2.3% increase for those three envelopes overall. 

There is also another $10 million for the Behavioural Support program.  Some (but not all) of that will wind up supporting LTC.  The Province says it is working towards the goal of a Behavioural Support Ontario (BSO) resource in every long-term care home in Ontario.  Funding will also be provided to expand the “work already underway in the long-term care sector to improve access to training and supports for quality palliative and end-of-life care in long-term care homes.” They don’t put a dollar amount on this last item, so it is probably not much.

There was nothing in the Budget about new LTC beds and Advantage Ontario did not even mention it in their response (although they had made a big deal of this prior to the Budget).  The government continues to redevelop old beds.

Compared to other provinces, Ontario LTC funding relies on extraordinarily large private payments from residents for accommodation.  So this fourth envelop of funding is not so significantly affected by the Budget.

Home and Community Care: As per usual, the “Province is expanding home and community care programs, including home nursing, personal support and physiotherapy services, with an additional investment of $250 million this year.” 

These $250 million increases have gone on for some years, so there is not much reason to think that this will do much to remove the backlogs or stop the reductions in service to less ill patients than we have seen in the past several years. 

Ontario Drug Benefit Plan expansion:  “OHIP+” will be available to all children and youth under 25, regardless of family income. It will completely cover the cost of all medicines funded through the ODB Program. There will be no deductible and no co-payment. This should reduce the costs of employer-based drug plans. The government reports an annual cost of $465 million.

The Gold -- Government Revenue: Ontario nominal economic growth was a third higher than expected in 2016 (4.6% versus 3.4%).  The Province's tax revenue estimate for 2016/17 is up $3.2 billion more than the 2016 Budget and $1.2 billion more than the Fall Economic Statement. So, they now expect to end up with 3.5% more tax revenue than planned in the Budget. Unfortunately the government also revised its estimate of carbon allowance proceeds downwards by $500 million so the total overall increase for 2016/17 is up $2.6 billion over the 2016 Budget estimate overall, about 2% more than planned.

Similarly, the revenue estimate for 2017/18 is up $3.9 billion and up $3 billion for 2018/19 compared to the 2016 Budget estimate for those years. These are positive but not surprising changes, given better than expected real and nominal growth in 2016.  

Note however, the increase in expected revenue is entirely driven by greater than expected tax revenues – the other areas of government revenue (government business revenue, federal transfers, carbon allowance proceeds, and “other” non tax revenue) are generally dragging revenue expectations downwards over the next few years.

In total revenue grew 3.8% in 2016/17 (almost $5 billion) after bumper revenue growth of 8.3% (almost $10 billion) in 2015/16. 

The government hopes for significant increases in revenue in 2017/18 -- over 6%. Increased tax revenue and a one-off increase in “other” non-tax revenue are supposed to be the key factors in this growth. That level of revenue growth is important for their zero deficit goal. A pause in economic growth or nominal economic growth could create problems.   

But we may not have heard the full story on revenue for even 2016/17.  Last fall, the final accounting for 2015/16 in the Public Accounts  added a surprising $1.9 billion to revenue, significantly improving the books at the last moment. That would certainly improve future revenue prospects -- if it happens again.     

Net Debt as proportion of the economy falls for third year in a row: Progressive Conservatives, rightly fearing (from their conservative perspective) the potential for increased pressure for improved public programs, have begun to re-focus on the province's debt accrued over the years. With the deficit gone, that argument against public social programs is mortally wounded (although the PCs haven't quite given up all hope they can find some way to breath life into the deficit monster). 

However, even the new "debt" line of attack on public programs has been weakened. The province's net debt as  a percentage of GDP (see bottom of the chart below), the key measure of the province's ability to pay its debt, is now planned to be over 1.6% lower than its high in 2014/15 of 39.1%. More cuts in the debt to GDP ratio are quite possible. 

The Future: The government expends a fair bit of energy diverting attention to future health care funding increases.   They claim they are going to increase health care funding 4.7% in 2018/19 (see the funding numbers in the chart up top).  

That would be just in time for the election. 

It would also put health care funding increases closer to health care cost pressures, albeit  still below the level set by even conservative advisers. According to the Budget, this would also be more than double the increase other ministries would get, for a change.

In any case, for 2019/20 (after the election) they only promise a 3.1% health care funding increase. 

Hopefully, this is just an opening salvo. It would be a pity if the “booster shot” wore off after the election.


Cash give-aways haven't helped the Liberals so why double down?

The government has answered the question about who might benefit from the improved fiscal situation of the province.  At least in part.

The government's announcement that they will spend $2.5 billion over three years on hydro subsidies (an average of  $833.3 M per year) takes them further down a road they have already tried, without much to show for it.  

Premier Kathleen Wynne implicitly confirmed growing government revenue but cautioned that this latest cash give-away is putting them closer to falling back into deficit.  She stated:
"Thanks to a provincial economy that is leading all of Canada growth, we can make this change and stay on track for a balanced budget next year and the years to follow.  But it’s going to be a lot harder now and we’ll remain a lot closer to the line."
So far these sort of cash give-aways have accounted for the large majority of the new, in-year spending that has marked the tentative move away from government austerity that began last fall. 

The conclusion the government seems to have drawn from their huge hydro cash give-away in the fall (the "HST tax cut") is that it wasn't enough. 

So they have doubled down.

Well it's true that the previous cash give-away hasn't helped the government's polling numbers.

But will more cash give-aways help them any better? It's pretty easy to forget about something you are no longer paying. 

In contrast, it's hard to ignore mounting problems in your public services. 

New funding announcements aimed at simply maintaining public services amount to only a small fraction of the cash give-aways announced.  

As a result, public services are still starving on an austerity diet.

Wynne's comment, noted above, seems aimed at managing expectations that there are more spending announcements to come. But with an election just over a year away, a Budget in the offing, growing government revenue, and perhaps little to show for the cash give-aways, there probably is more to come.  

But surely no more tax cuts or cash give-aways. 

For his part, Patrick Brown now feels compelled to release Progressive Conservative (PC) hydro policy in the next few weeks. This is a change from the cloak of secrecy he has put up around PC policy, whatever it is. Previously the plan was to announce PC policy at their November convention. 

But there is no sign yet that they will announce anything early about their health care policy.   Who knows what they might do -- hospital cuts? more austerity? Exactly what Brown stands for is as clear as mud.