Ontario to cut funding for hospital infrastructure in half. Austerity bites

The Ontario government recently put out a release bragging that they will fund $50 million per year to renew existing hospital facilities. 
old Ontario hospital x-ray

However, in her September report the Auditor General reported that Ontario hospital funding is less than the renewal needs for existing hospitals. "The assessments of hospital facilities identified $2.7 billion dollars of renewal needs, requiring annual funding of $392 million to bring assets to what is considered good condition. However, since 2014/15 actual annual provincial funding has been $125 million..." 

In other words, the government has put out a release announcing that they are reducing hospital capital renewal funding -- from a level that was already only a fraction of what is needed to bring hospitals to good condition.

The release also brags that they will provide $12 billion over ten years for new hospital facilities (as distinct from funding to renew existing hospital facilities discussed above). That works out to about $1.2 billion a year -- but even this aspect of the announcement is also much less than it appears.

Over the previous five years (2011/12-2015/16) the government spent $14.8 billion in hospital infrastructure (as reported on an interim basis in the Budgets). That is very close to $3 billion a year.

So, in other words, the government is reporting that it will cut spending on hospital infrastructure by over 50% - or by about $1.7 billion per year.

It takes some chutzpah to put out a release bragging about your funding when you are actually cutting funding. 
Ten year plan for Ontario hospital facility funding

Source: Ontario Budget Papers (interim estimate from following year's Budget)

But it's even worse.  The Auditor General also noted: "Existing funding does not address significant pressures faced by ministries for new projects... the Ministry of Health and Long-Term Care has received submissions for 37 major hospital projects totalling $11.9 billion dating back to 2005/06. These submissions were endorsed by Local Health Integration Networks as needed projects requiring funding. However, the Ministry did not put forward these projects for approval to Treasury Board as these initiatives could not be managed from within their existing budget allocation."

So even with much higher funding than they now propose, $11.9 billion in needed hospital infrastructure projects could not be done.  

Notably, even with the much higher infrastructure funding, hospitals raided operating funds for capital projects. The Auditor reports that in "the last five years, hospitals spent on average $45 million a year of operating funds on capital and other funding needs." 

Given this announcement, this transfer of funds from hospital services to hospital facilities looks set to intensify.  That's especially bad news when hospitals have seen their real funding for services cut for many years.

Ironically, this announcement comes just after an infrastructure obsessed Budget.  The 2016 Budget increased funding for infrastructure projects by over $3.3 billion compared to the previous year. 

Provincial funding of infrastructure 2016

Pictures: epicmoments Inside an abandoned hospital in Ontario. TGH Wikipedia. 


Ontario hospital length of stay in rapid decline, Canadian average now 21% longer

New hospital inpatient length of stay data published by the Canadian Institute for Health Information (CIHI) indicates [1] Ontario lengths of stay continue to decline, but the pace of decline has picked up, and [2] the gap between the Ontario and Canadian average length of stay is growing and has now hit startling levels.
  • Since 2007/8, Ontario inpatients have 0.6 fewer days in hospital. This is a decline in length of stay of 8.7%. The Canadian average declined only 0.1 day (1.3%). The Ontario decline corresponds with the real funding cuts for Ontario hospitals in recent years.
  • Much of this occurred in the last year -- Ontario inpatients had 0.3 fewer days in 2014-15, a decline of 4.6%.
  • The Canadian average is now 1.2 days longer – or, put another way, Canadian patients stay 19% longer. This corresponds with the extra funding Canadian hospitals get compared to Ontario hospitals. 

Canadian hosptial length of stay 21% longer  than in Ontario

The trend is even more apparent if we look at “age standardized average length of stays” (which standardizes the age of patients for all jurisdictions and time periods and so is probably a more accurate measure).
  • Since 2007/8 length of stay has declined 1 full day in Ontario – a 14.9% decline. 
  • In the last single year reported (2014/15) the age standardized lengths of stay declined half a day in Ontario – or by 8.1%.
  • The gap with the Canadian average has grown from 0.6 fewer days in Ontario in 2007/8 to 1.2 fewer days in Ontario. 

In other words, in 2007/8 the Canadian average stay for an age standardized patient was 8.9% longer, but in 2014/15 that had grown to 21% longer. Quite incredible.

Ontario age standardized length of inpatient stay declining -- and far shorter than Canadian LOS

The government has focused on removing less sick patients from hospitals and treating them at home.  So the decline in length of stay has occurred while the patients in the hospital are relatively sicker.

The more rapid decline in length of stay fits directly with the harsh funding restraint imposed on Ontario hospitals in the last few years and the increasing re-admission of patients to hospitals in Ontario.  This CIHI chart shows the number of patients per 100 patients who must be readmitted within 30 days, a major increase in a few short years.  This means that means about 9,000 more patients must now be re-admitted to Ontario hospitals every year.

Canadian hospital inpatient re-admissions increasing

In just four years between 2009/10 and 2013/14 Ontario saw a 13.6% decline in the age standardized length of stay and a 9.6% increase in re-admissions.


Ontario loses 19,000 public sector workers while rest of Canada gains 73,000

Ontario loses 19,000 pubic sector jobs in two yearsThere has been a general trend downwards in public sector employment in Ontario according to Statistics Canada.

In the last two years, Ontario has lost 19,000 public sector workers, with most of the loss occurring in the last year.
Ontario falling behind Canada in terms of public sector jobs
The downwards trend in Ontario contrasts with the upward trend across the rest of Canada. 
73,000 new public sector jobs
While Ontario lost over the last two years, the rest of Canada gained 73,400. Over the last year the rest of Canada gained 65,300 public sector jobs, while Ontario lost 12,700 public sector jobs.

This may understate the cuts in the Ontario broader provincial public sector (i.e. public sector workers, like health care workers, that are primarily funded by the province, excluding federal and municipal employees). Austerity has been much harsher for the Ontario government than the federal and Ontario municipal governments. So the Ontario broader provincial cuts may be softened by modest growth in the federal and municipal sectors.

The level of public sector employment was already much lower in Ontario than in the rest of Canada -- and with austerity in Ontario that gap is growing rapidly.

Ontario public sector jobs decline as percentage of population

If Ontario had the same level of public sector employment as the rest of Canada in 2015, there would be an additional 1.06% of the total population working in the public sector.  Ontario is missing 146,196 public sector workers compared to the rest of Canada on per-capita basis. 

Two years earlier the gap was only 0.63% -- or 85,371 fewer public sector workers. On a per-capita basis, Ontario has fallen 60,825 public sector jobs further behind the rest of Canada in one year. 

Worse to come?  The decline in Ontario public sector workers has been driven by provincial public sector austerity in the last few years.   Program spending (which pays for broader provincial public sector jobs among other items) saw increases decline to 2.9%, 2.1% and 2.2% over the last three years (2012/13 through 2015/16), well below government cost pressures of inflation, population growth and aging.  

But now the new Ontario Budget indicates the real public sector cuts will get worse. For this coming year, 2016/17, they propose to cut that increase to less than 1%, less than half the increase in 2015/16.  

Ontario is the lowest spending, lowest revenue provincial government -- but this comes with far fewer public sector workers. And with the new Budget, this is set to get worse.  

When you need a health care worker, this reality will come home to roost.

Public sector jobs in Canada and Ontario
Sources: Statistics Canada,  Labour Force Survey 282--0089 and Population by year and by province and territory


Health Care and the Budget: Not Much

Health care and hospital funding: Despite significant new revenue and lower than expected debt costs, health care spending is almost exactly identical to the amounts planned in last year’s Budget for 2015-2018. 

The total health budget for 2015/16 came in (on an “interim” basis) basically the same as planned in the 2015 Budget (that is unusual, more often they under-spend the health budget).   

For 2016/17 and 2017/18, they plan to keep basically to the targets set out in the 2015 budget (plus a small increase of $100 million in each of those two years -- an extra 0.2%). 

Overall, health is planned to increase 1.97% in 2016/17 and 1.93% in 2017/18. That will see health expenditures fall again as a percentage of the economy but is a little bit higher than the planned all-program expense increase (of 1% in 2016/17 and 1.7% in 2017/18).  That is far short of costs pressure due to increased utilization, aging, population growth, and inflation. 

Hospitals are budgeted to receive $345 million more in 2016/17 than in 2015/16. Based on CIHI estimates of provincial hospital spending in 2015/16 ($19.4187 billion) that is an increase of 1.78%.   

If actually realized that is a bigger increase than CIHI reports for provincial spending on hospitals in recent years:

While a little better than what we have seen, this will fall far short of cost pressures, with the result that hospital cuts and layoffs will continue. 

The government claims a 1% increase in base (or global) hospital funding -- but given that they have shrunk the role of global funding that only amounts to $60 million (0.31% of total hospital funding).  

Combined with $100 million new money for activity based funding (based on fee for service payments) and "HBAM" funding (based on population and demographic factors), total regular hospital funding is going up $160 million – or an increase of about 0.82% of total provincial hospital funding.  

Another $175 million increase for hospital funding is coming through “provincial programs” funding. On February 29th, the government claimed that this was for "access to more services in new and redeveloped hospitals" (post construction operating funding) "and for targeted priority services such as organ and tissue transplants."  The remainder of the $345 million is being set aside for small, rural, and northern hospitals (reportedly $7.5 million) and mental health hospitals.

Bottom line – we have been successful in moving them off the freeze to base (global) funding, but only in a very, very modest way.  Real hospital funding (and real health care funding) is still in steep decline.

Hospice Care: The government is investing an extra $75 million over the next three years to increase funding for hospices to almost $55 million per year in the third year.  The government sees hospices as more 'cost-effective' than hospital palliative care beds. 

Long Term Care – 2% increase for the nursing and personal care envelope. No word on the other funding envelopes

Home and Community Care: $250 million increase -- they put this at “about” a 5% increase and increases at this level will continue through 2017/18.   Community Care Access Centre (CCAC) funding is roughly half the total home and community care funding, but there's no word, yet, on the portion of the increase CCACs will get.

Family Health Teams, Community Health Centres and Nurse Practitioner-Led Clinics: To "ensure" these primary care clinics can effectively recruit and retain qualified (non-physician) staff, Ontario will invest an additional $85 million over three years. Compensation for workers in the largely non-union community health sector generally lags, and this may be a real attempt by the government to help with catch-up for at least one group of workers who have been negatively affected by that trend. But there's an awful lot of other community health workers that need this sort of help just as much.   

Deficit: No surprise -- for the seventh year in a row the government beat their deficit forecast.  Indeed, for 2015/16 they beat their 2015 Budget estimate by $2.8 billion by lowering the deficit to $5.7 billion. They even beat their forecast for the deficit in their fall economic statement of just a few months ago by $1.8 billion.  Notably, they reduced the deficit by $4.6 billion compared to the previous year (2014/15).  With another $150 million still being held by the government in reserve, the 2015/16 deficit may fall further still by the time they close the books on this fiscal year with the Public Accounts in the fall. 

Their new (and lowered) estimate for 2016/17 is $4.3 billion, ½ a billion less than the estimate in the 2015 Budget. As this is only $1.4 billion less than 2015/16 and they lowered the deficit by more than three times that amount between 2014/15 and 2015/16, this deficit estimate may also prove high, as has been the case so often in the past.   Barring changing economic circumstances, they are well placed to hit their zero deficit target for 2017/18 (despite all the naysayers). 

Notably, net debt as a percentage of the economy (GDP) is expected to stop increasing this year and then start to decline, a key positive development. 

Ontario's debt situation is improving
Total Program Expense: They have budgeted significantly more for 2016/17 than in the 2015 Budget.  While the 2015 Budget planned increased program expenditure of a modest $100 million in 2016/17 and a cut of $600 million in 2017/18, they are now planning significant increases:

2015 Budget:
2015/16 -- $120.5 billion
2016/17-- $120.6 billion
2017/18--$120.0 billion

2016 Budget:
2015/16 -- $120.9 billion
2016/17-- $122.1 billion
2017/18--$124.2 billion

So the “good” news is program expense is up $1.5 billion for 2016/17 and $4.2 billion for 2017/18 compared to the plan in the 2015 Budget.

But the much more telling bad news is that this is mainly going to men and the private sector

As noted, health care did not get any significant boost.  Of the $4.2 billion in new spending planned for 2017/18, health care will get 1/42nd of that. For 2015/16, health care got 1/15th of the new spending.  Apparently, if there was anyone fighting for more health care dollars in the Liberal cabinet, they lost. 

What did get a significant boost is “other programs”.  Under the previous Budget this item was supposed to decline at a very rapid pace – 5.5% per year. Now they are going to increase 3.2% on average.  As a result “other programs” are slated to be 7.14% higher than budgeted in the 2015 Budget for 2016/17 and a whopping 22.9% higher in 2017/18.  Quite a change. 

The cuts in spending for “other programs” forecast in the 2015 Budget  were put down to efficiencies (e.g. cuts) found in various programs and cuts to the teachers’ pension expense.  While those reductions, I will wager, remain, other expenses are going up.  The 2016 Budget papers explains the increase by reference to “investments in transit, transportation , and community infrastructure, enhancement of GO Transit, the Long-Term Affordable Housing Strategy and initiatives to support Ontario’s Climate Change Strategy."

Infrastructure expenditures are planned to increase 25.5% in 2016/17 to $16.24 billion.

Capital spending increases in Ontario

In contrast, public sector (often female) jobs have fallen for the last two years in Ontario (click here for more on this). With the real cuts in this Budget, this trend will continue. 

Bottom line: While there is precious little new for female dominant, public sector health care services, male dominant, private sector construction industries are getting a windfall boost.  So much for gender equity.

Economics: Real growth in Ontario is forecast to slow from 2.5% in 2015 to 2.2% in 2016 and 2.4% in 2017.  But even on this basis, Ontario will beat Canada for the third year in a row in 2016, and by quite a ways. Unemployment levels are also now better than the Canadian average (6.7% versus 7.2%).  

Other good news is that nominal growth (growth plus inflation) will pick up from 3.6% in 2015 to 4.0% in 2016 and 4.6% in 2017.  Nominal growth is the key driver of revenue growth, so this would drive up revenue. 

Update: On March 3, the chief economist of the Financial Accountability Office of Ontario noted that "the budget assumes nominal GDP growth slightly above that of private sector economists."  So there is some question about the government's nominal GDP and, therefore, its revenue forecast.  Tracking nominal GDP will be key. 

Inflation is forecast in the 1.8-2.0% range.  Program spending continues its rapid decline as a percentage of the Ontario economy (down 2.2% compared to 2009/10). 

Although interest on debt continues to increase (with the deficits), it is now estimated at significantly less than in last year’s budget ($600 million less for 2016/17 and $700 less for 2017/18).  Rock bottom interest rates are opening up a bit more space for program spending than expected.

Bargaining - They continue to boast about how much lower settlements in the broader provincial public sector are compared to settlements in the municipal, federal, and private sectors.  The reported gap is significant. 

In the government's view, major broader provincial public sector settlements have a "net-zero" cost for the government.  They also flag the consolidation of school board health, life, and dental benefit plans. They expect improved cost efficiency, long term savings, and believe this will be one of the biggest consolidations and rationalizations of benefits in Canada.   A key goal is harmonization of benefits as over 1,000 plans will be consolidated into a handful of trusts. 


Declining Health Care Funding in Ontario

Federal Health Cash Transfers ("CHT") to the Ontario government will rise 5.94% in 2016/17, or by $778 million. This, in itself, would pay for a 1.5% increase in Ontario health care funding even without a single extra penny from Ontario tax revenues.  This follows a $736 million increase (5.96%) to federal health care cash transfers to the province of Ontario for this year.

Despite this, the Canadian Institute for Health Information (CIHI) estimates that total health funding by the Ontario government is only going up by about $352 million this year -- or about 0.7%. This falls well short of aging, inflation, utilization, and population growth cost pressures and deepens  the trend in recent years to reduce health care and hospital funding in real terms.  So far, there are precious few signs that the government will reverse its policy of health care austerity in its upcoming 2016/17 budget. Likely, Ontario funding will fall far behind federal health care funding once again:

Health Care and Hospital Funding Declining as a Share of the Economy: As a percentage of the total economy, Ontario government health spending has declined consistently since 2009-2010, when it is was at 7.6% of Gross Domestic Product. Last year it was at 7.15%, and this year it is 6.91%.  

hospital funding in Ontario - chart


Ontario health cafe funding declines as percentage of GDP

The current Budget plan is to increase Ministry of Health and Long-Term Care funding by 1.8%  (to $51.7 billion) in 2016/17 and by 1.9% (to $52.7 billion) in 2017/18. With nominal GDP expected to go up at a much quicker rate, health care funding would continue to decline as a percentage of the economy.

Hospital funding is also declining as a percentage of the economy:

Ontario hospital funding declines as percentage of GDP

CIHI figures  indicate that (contrary to widespread suggestions) Ontario provincial health care funding has been falling as a percentage of total provincial government program spending.

health spending declines in Ontario

According to data in the 2015/16 Ontario Budget, this trend continues with Ministry of Health and LTC funding falling from 38.8% of total program spending last year to 38.5% this year.  This directly contradicts claims by many that health care would assume a much larger portion of program spending.  

But this squeeze on hospital and health care funding comes with consequences. Here's two:

Nursing: Ontario has far fewer nurses working in hospitals than the rest of Canada according to CIHI data.

more nurses in rest of Canada compared to Ontario

Most (but not all) of this is driven by fewer practical nurses in Ontario hospitals compared to the rest of Canada:

More practical nurses in rest of Canada than Ontario

Currently, Ontario has 1.11 practical nurses working in hospitals per 1000 population while the rest of Canada has 1.74 practical nurses. In other words, the rest of Canada now has 57% more practical nurses working in hospitals per capita than Ontario does.

This lack of resources results in significantly fewer nursing hours per patient in Ontario according to CIHI data:

Hospital inpatients with the same condition can expect to receive 16.6% more nursing care if they are treated at a typical Canadian hospital than if they are treated at a typical Ontario hospital. 

Re-admissions: Coinciding with the cuts is a large increase in hospital re-admissions. Canadian Institute for Health Information indicates that across Ontario the number of all patients readmitted to hospital has increased since 2009-10 through 2013-14 from 8.3 per 100 patients to 9.1 per 100 patients. This is an increase of 9.6% over just four years. In other words an extra 9,000 patients have to be readmitted to hospitals each year compared to four years earlier. Moreover, Ontario has gone from having below average re-admissions to above average re-admissions compared with Canada as a whole:

Ontario hospital readmission now higher than rest of Canada

To deal with these problems the Ontario Council of Hospital Unions has called for:
  •          Significant ongoing increases to hospital, LTC and home care funding to offset population growth, aging, and inflation, as well as  increases to offset the funding lost in the last several years
  •         Ontario, as a relatively wealthy province, should aim to fund and provide care at the same level as the other provinces or better.


Performance Problems: 37 Health Care Issues from the Auditor General

The litany of health care problems identified by the Auditor General in her 2015 report is frightening. Here's thirty-seven of them dealing with LHINs, LTC, EMS, Rehab Hospitals, Health Infrastructure, Home Care, and Health Human Resources.

Local Health Integration Networks (LHINs): A Lot of Problems

Rising re admissions in Ontario hospitals

  1. LHINs have not met performance expectations. "Most LHINs performed below expected levels in the year ending March 31, 2015. In that year, LHINs on average achieved their respective local targets for six of the 15 performance areas".  Also: "Based on the provincial results that include all 14 LHINs, only four of the 11 provincial targets that measure long-term goals for LHINs were met."
  2. Performance has not improved. "While province-wide performance in six of the 15 areas measured has improved between the time the LHINs were created and 2015, in the remaining nine areas, performance has either stayed relatively consistent or deteriorated since 2010 or earlier". 
  3. The Auditor also found that the performance gap between LHINs has widened over time in 10 of the 15 performance areas.
  4. There are bigger health care problems in northern and rural areas. The government promised to develop a health care plan in 2007 for rural and northern areas but failed to do so.  Given the ongoing problems, the Auditor General has recommended that the province develop this plan, as promised.
  5. The Auditor recommends that MOHLTC "should determine how best LHINs can manage the primary-care sector." Currently, LHINs do not oversee primary care (except for Community Health Centres).The Ministry says it "accepts this recommendation and will examine ways the LHIN role in primary care can be strengthened".
  6. Neither the Ministry nor the LHINs routinely verify that the information health service providers submit to them is accurate and reliable. "Without such verification, the Ministry and the LHINs cannot be certain that health services are being provided as expected, nor can they be assured that significant errors in reporting has not occurred." The LHINs show no interest in verifying the data, replying: "The LHINs and Ministry acknowledge the importance of high-quality data for decision making. Accountability for reporting accurate and timely data lies with the health service providers."
  7. Processes used to plan and integrate the health system need improvement. Notably, the Auditor notes the "LHINs could do more to define system capacity (that is, how service supply meets current and future demand for service)."The recommendation is for the LHINs to"begin to collect, over a reasonable time period, the data needed to determine the existing capacity of all health services in their regions"
  8. The LHINs should "identify further group-purchasing and back-office integration opportunities in the various health sectors, and implement these cost-saving practices." The LHINs say they will "support" such integration but note that that they will on clinical integration instead: "Consistent with the LHIN mandate, LHINs will continue to lead and focus on service integration (i.e., the integration of service delivery to patients, clients and residents) for the benefit of residents."
  9. The LHINs don't consistently measure the cost savings achieved (or not) by mergers and integration. "Only one of the four LHINs we visited tracked the cost savings that resulted from its integration projects, and then only on merger-type projects." The LHINs response sounds like they will find a measurement system that will prove these integrations are saving money: "LHINs will work toward developing a standard framework in which to identify and measure the impact of these integrations demonstrating overall value for service providers, patients and the system."
  10. The Ministry of Health and Long-Term Care should review existing LHIN boundaries. The Ministry indicated that it will review the existing LHIN boundaries to determine whether changes may be required.
  11. "LHINs are not notified of funding changes on a timely basis, and in turn do not in due course notify the health service providers they fund, resulting in cases where funding originally earmarked for health service providers is returned to the Ministry." (This may help explain the tendency for the MOHLTC to under-spend its budget.)
Comment:  [A] There are significant performance problems. Despite this, the government is reducing resources for health care.  [B] There is scant evidence that the government driven integrations and mergers of health services providers are saving money.  Notably after the Harris government required hospitals to merge, significant evidence arose that this had driven costs up, not down.  [C] There is little attempt to measure the needed capacity of the health care system.  Despite this, the government is systematically reducing the resources available to the health care system, and especially hospitals. [D] The bigger problems for health care in northern and rural Ontario are no doubt connected with the failure of the government to develop a good health care plan for northern and rural Ontario, as it had promised in 2007. We need a solid plan to deal with these issues.  

Problems with LHIN health care performance

Long-Term Care Quality Inspection Program: Repeated Non-Compliance

    Municipal LTC homes in Ontario
  1. The Ministry of Health and LTC (MOHLTC) is not following up on long-term care "situations placing residents at risk. "Specifically two-thirds, or about 380, compliance orders due in 2014 had not been followed up within the Ministry's informal 30 day target."
  2. "The Ministry’s actions are not sufficient to address the repeated non-compliance in certain long-term-care homes—We noted that homes in one region did not comply with almost 40% of the compliance orders issued by the Ministry in 2014, while homes in another region did not comply with about 17% of orders."
  3. The Auditor General notes, "Ontario legislation does not require a minimum front-line-staff-to-resident ratio at long-term-care homes—Home administrators identified insufficient staffing and training as the main reasons for their failure to achieve compliance. In 2014, long-term-care homes provided an average of 3.4 direct care hours per resident per day, while the Ontario Association of Non-Profit Homes and Services for Seniors recommends four hours. Home administrators also said that the provincial funding of $7.87 per resident per day is not sufficient to meet residents’ nutritional needs (three meals plus two snacks)."

Note the ongoing problems in the homes and the connection made to under-staffing.  

Problems in Long-Term Care

Infrastructure: Inadequate hospital funding
  1. Ontario funding is less than the renewal needs for existing hospitals. "The assessments of hospital facilities identified $2.7 billion dollars of renewal needs, requiring annual funding of $392 million to bring assets to what is considered good condition. However, since 2014/15 actual annual provincial funding has been $125 million and prior to that, since 2010/11, only $56 million was provided." 
    Inadequate capital funding for Ontario hospitals and schoools

  2. Hospitals "have had to use operating funds to fund capital" projects. "In the last five years, hospitals spent on average $45 million a year of operating funds on capital and other funding needs."
  3. Funding is less than needed not just for renewal of existing facilities, it is also inadequate for required new facilities. "Existing funding does not address significant pressures faced by ministries for new projects... the Ministry of Health and Long-Term Care has received submissions for 37 major hospital projects totalling $11.9 billion dating back to 2005/06. These submissions were endorsed by Local Health Integration Networks as needed projects requiring funding. However, the Ministry did not put forward these projects for approval to Treasury Board as these initiatives could not be managed from within their existing budget allocation."
  4. There is a bias in funding allocations towards new facilities at the expense of renewing older facilities.
Comment: Earlier reports by the Auditor General's office have documented how privatized public private partnerships (P3s) -- the government's preferred way of developing new facilities -- are wasting billions of dollars of public money.  Now it turns out that the  government is biased towards developing new facilities at the expense of renewing existing facilities. Righting this imbalance by focusing more on renewing existing facilities would put the crimp on those P3 corporate rip-offs.   Spending too much on new P3 facilities is especially bad given that the Auditor also finds that we are not doing enough hospital infrastructure projects to keep up with needs.  With most of Ontario hospital facilities over 31 years old, that spells trouble so we certainly cannot afford to waste what we do spend on privatized P3s.
Most hospitals are over 31 years old

Paramedic Services ("Ambulance"): Improving response
  1. A July 2015 consultants report collected data from 14 of 50 municipal delivery agents. "The consultant concluded that there were limited opportunities for operational efficiencies that would result in cost savings. This was primarily due to all municipalities using unionized staff with relatively similar wages across Ontario. However, the report also noted that improved call triaging could reduce costs overall in urban municipalities. Therefore, the consultant recommended that the province work with municipalities (especially larger urban ones) to increase the accuracy of dispatch systems’ prioritizing of calls. The Ministry is planning to address this recommendation in the Provincial/Municipal Land Ambulance Dispatch Working Group’s report, expected in fall 2015."
  2. The Auditor claimed little progress on minimum service levels and promotion of efficient delivery. "The consultant noted that the Ministry’s current performance measures do not reflect the key outcomes of land ambulance services and recommended that the Ministry review the current measures. The Ministry plans to share the consultant’s report with the OAPC (the paramedic Chiefs) in fall 2015 and then develop processes to promote more efficient land ambulance services by March 31, 2017"

Comment: Improvements in dispatch protocols will help paramedics respond more rapidly to emergency calls.  The other recommendations in the consultant's review, reportedly to be released to the Chiefs in 2015, should be closely followed. 

Rehabilitation hospitals: Rising demand
  1. This sector will expand as the population ages, particularly as the baby boomers turn 75. Still the Auditor notes that "approximately a third of patients admitted to inpatient rehabilitation at the two hospitals we visited with stroke programs had been assessed by an acute-care hospital as having mild functional impairment. This suggested they might have been better served in outpatient programs if these less costly services were available."
  2. There is no co-ordinated rehabilitation system in Ontario.
  3. "There was wide variation in the supply of regular rehabilitation inpatient beds across the province, which could mean that patients had to travel outside their LHIN for services. The number of beds ranged from 57 per 100,000 people in the Toronto Central LHIN to only six per 100,000 in the Central West LHIN. The provincial average is 18 beds per 100,000."
  4. The Ontario Hospital Association reported that, as of March 2013, about 2,300 alternate-level-of-care patients who were ready to be discharged were waiting in acute care hospital beds for arrangements to be made. Of these, 25% were waiting for a regular rehabilitation bed or a complex continuing care (which includes restorative rehabilitation) bed.

Comment: With almost 600 patients waiting in other hospital beds for a rehabilitation bed, more rehabilitation hospital beds will significantly reduce alternate level of care patients in hospitals.  Most of the other patients are waiting for LTC beds -- but there is precious little sign that the government wishes to expand either LTC or Rehab capacity.

Community Care Access Centres (CCACs): Wait lists and varying service
  1. Clients are still put on wait-lists and have to face long wait times to obtain personal support services.
    CCACs are taking too long to assess home care clients
  2. 2. Clients with the same assessed needs still receive different levels of services depending on where they live in Ontario.Unequal access to home care in Ontario
  3.  CCAC funding is predominantly based on what each CCAC received in prior years rather than on actual client needs and priorities.
  4. CCACs are unable to provide personal support services to the maximum levels allowed by law. 
  5. Care co-ordinators’ caseload sizes vary significantly, and some exceed suggested ranges in standard guidelines
  6. Clients may not receive appropriate levels of services as CCAC care co-ordinators did not assess or reassess clients on a timely basis
  7. Not all care co-ordinators maintained their proficiency in, and some were not regularly tested on, the use of assessment tools
  8. CCAC oversight of contracted service providers needs improvement
  9. CCACs do not consistently conduct site visits to ensure service providers are complying with their contract requirements. The lack of site visits to contracted service providers by the CCACs, and the CCAC reliance on self-reporting by contracted providers, does not sufficiently mitigate the risk of under performance or billing inaccuracies. The Auditor consequently recommends the CCACs should conduct routine site visits to monitor quality of care and verify the accuracy and completeness of information reported to CCACs. The CCACs appear to be uninterested in this, noting that they see value in mandatory provincial requirements for automated reporting to the CCACs.
  10. The MOHLTC should expedite diverting low-need clients from CCACs to community support service agencies. The MOHLTC supports this. A phased implementation is going ahead, beginning with four early adopter LHINs. This reform will reduce the CCAC scope of work
  11. CCACs should require that all CCAC care co-ordinators comply with the minimum number of assessments per month and be tested on the use of the assessment tools each year
  12. The Auditor notes that the Ministry only requires contracted service providers to annually self-declare that they have complied with the government’s $4 an hour PSW wage enhancement and so recommends that the CCACs should conduct inspections of service provider records, on a random basis, and share the results with the MOHLTC.
Comment: The Auditor’s report supports some of CUPE’s home care concerns: [1] the CCAC wait lists and the inability of the CCACs to provide the maximum care allowed supports our contention that home care is underfunded; [2] The Auditor’s concerns that the CCAC oversight of contracted providers is inadequate bolsters our contention that, given almost 20 years of CCAC contracting, it is time to consider that contracting-out for vital health care services is the problem.

Per-capita home care funding in Ontario

Human Health Resources
  1. The Auditor General had previously identified that access to health care was a problem for some Ontarians, particularly those who live in rural, remote and northern areas of the province. As of 2011, 95% of physicians in Ontario practised in urban areas and 5% in rural areas. At the same time, 14% of the population lived in rural areas. 
  2. At the end of 2011, 66.7% of nurses were working full-time in Ontario, just slightly under the Ministry’s goal of having 70% of nurses working on a full-time basis.  This percentage dropped to 63.9% in 2014.

Charts: Auditor General 2015

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