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"The sum of all the numbers is a tightening nursing labour market," Karima Velji, president of the Canadian Nurses Association (CNA), said in a statement. "Immediate action is needed to stave off the potentially long-lasting trend of a shrinking [registered nurse] work force and its consequences for population health." The CNA is a professional organization that advocates for nurse-friendly public policy.

Andrea Porter-Chapman, CIHI's manager of health work force information, said it is too early to say whether the dip in supply marks the start of a nursing shortage in Canada or a one-year blip thanks to a regulatory change in Ontario. Either way, health policy-makers will need to watch the trends closely over the next couple of years, she said.

"This is the first shift in almost two decades where we've seen a decline in the supply," Ms. Porter-Chapman said. "But the positive side of this is that our work force continues to increase. ... I think [the supply issue] is something that our health-care system just needs to be aware of and monitor."

The supply of registered nurses - by far the most common nursing category - fell 1 per cent. At the same time, the number of nurses actually working in the field continued to climb last year, up 2.2 per cent from 2013, in keeping with the stable growth of the past 10 years.

But not all licensed nurses work in nursing. Some hold on to their licences after landing other jobs, going back to school or unofficially retiring. Last year, the College of Nurses of Ontario, the self-regulating body that oversees the profession in Canada's most populous province, put in place a new rule that effectively bars members from renewing their licences unless they have practised nursing in the province in the past three years. That contributed to an unusually high number of nurses formally exiting the profession in Ontario - 15,836 in one year.

Still, the CIHI report identified some underlying trends that suggest there is more at play. Across the country, a total of 27,757 nurses let their licences lapse last year, while only 25,397 registered anew with one of the provincial or territorial regulators - a net loss of 2,360.

The supply of nurses dropped in six jurisdictions: Newfoundland and Labrador (down 0.7 per cent), Prince Edward Island (down 3.5 per cent), New Brunswick (down 0.9 per cent), Ontario (down 2.6 per cent), British Columbia (down 0.9 per cent) and the Northwest Territories and Nunavut, which together saw a decrease of 3.2 per cent.

Canada's nursing schools are simply not graduating as many students. "We've seen the growth in the number of [nursing] graduates slow down, so it's just under 1 per cent now," Ms. Porter-Chapman said. "This is after five years where the growth was between 6 and 12 per cent."

As well, the number of students admitted to entry-level nursing programs actually fell between 2009-10 and 2010-11, the most recent year for which CIHI was able to obtain national figures. "Will the workplace feel it yet?

Perhaps not. It might take a year or two to see these changes trickle into work settings," said Linda McGillis Hall, a professor in the faculty of nursing at the University of Toronto. "I think this report will actually bring this issue to the forefront again."

nursing schools.

Nurses worked more than 21 million hours of overtime in 2012 at a cost of more than $952 million to the health care system, Silas said, adding it’s no coincidence nurses’ sick time also increased.

A 2013 study for the national union reported that an average of 18,900 publicly employed nurses were absent from work each week in 2012 due to illness or injury.

Needless to say Dorsey, likewise, cannot abide allowing Unifor and CUPE, the two other unions, to represent the health-care and support groups since there is nothing close to a majority share of representation in either. Instead, he argues that each individual union local is a union for this purpose and invites them and the relevant NSGEU locals to fashion amalgamations. They seem to be amalgamations in name only: "(it) can also take the form of an amalgamation in which each of the former unions continues to exist, perhaps only with a change in name. There can be minor changes with the unions (by which he means the relevant union locals) continuing to operate with their pre-amalgamation structures and organization essentially unchanged." In other words it looks like a bargaining association, which the government has rejected, dressed up in different clothes. Worse, it preserves obsolete boundaries for no reason that benefits members.

Dorsey argues that the amalgamations meet the province's requirement for single bargaining agents, and that what he is proposing is "not a council of trade unions, not a bargaining association and not a joint structure of autonomous unions." Union leaders are getting a different message. They believe that they can keep their members after amalgamation. How can such an arrangement serve the interests of the new union's members? Since there is to be only one contract, why is there a continuing need for different locals? He invites the unions to create amalgamations for the health-care and support groups, but he does not exclude it for the others. The members of these new creations will not have voted for them - so much for majoritarian principles.

It's time for government to get a grip. It was not expecting this outcome. The process has already dragged on longer than it was supposed to, and no conclusions on representation have been reached. The unions may not reach an amalgamation agreement, or may present one that government views as unsatisfactory, but which Dorsey chooses to accept. The government must define clear timelines for a complete decision on representation to be reached, and specify the conditions it expects, including the degree of autonomy, in any new amalgamations that are proposed as candidates. The government has patiently and effectively moved this file along since the day it was elected. It should not let the project become derailed at this late stage.

"We are trying to live within the means we have," Pellizzari said, adding she wishes the health unit could offer more. "It's not what they want. It's not as much as they deserve." Bargaining unit president diane Lockman, a public health nurse for the health unit, could not be reached for comment Wednesday. She has said previously that she and her co-workers aren't paid as much as their colleagues in neighbouring communities. "We are asking our employer to acknowledge the important work we do by putting a fair and equitable offer on the table -one that prevents us from falling further behind the other public health and registered nurses in the area," she stated Tuesday.

OnA president Linda haslam-Stroud said the wage disparity is as much as 23%. "While the vast majority of Ontario's Rns have received small wage increases, OnA members with the Peterborough County- City health unit are the lowest-paid in the surrounding four health units," she stated Tuesday.

The health unit is following the direction of a province that is putting austerity measures in place, Pellizzarri said, noting the situation could improve in a couple of years. non-unionized staff have been told to expect 0% wage increases during that time, she said. A strike and resulting service disruptions are not a something anyone hopes for, she added. "We hope we can keep talking ... (a strike) is the last thing we want to see."

Last week, Ontario's Expert Panel on Home and Community Care, led by nurse leader Dr. Gail Donner, issued recommendations that outline much-needed functional changes to our provincial system. Together with longoverdue structural re-alignment to maximize existing resources, these will position Ontario's publicly-funded and not-forprofit health-care system to not only meet the timely needs of all Ontarians, but to also serve as a role model abroad.

Reports profiling the perceived "failures" of the Canadian healthcare system are often a guise for privatizing our public system, and only serve as a distraction from resolving solvable issues. Canadians know better and they have consistently voted for universal Medicare. Dr. Doris Grinspun RN and Chief Executive Officer, Registered Nurses' Association of Ontario

But under current working conditions, Care Partners nurses are over-worked and stressed-out, paid by the visit, not by the hour, working many hours of unpaid overtime and with no paid vacations, said Castro. They also do their administrative work at home on their own time. "It's not just about money," said Castro. "A lot of our work issues all come back to quality of care issues." OPSEU is bargaining for a contract similar to what other agencies, such as VON, have in place for their staff, he said. Although CarePartners is working on a plan to look after its patients in the event of a strike, it's too soon to know whether there will be patients no longer able to stay in their homes, said vice-president Karen MacNeil. "It's too early to determine what the result would be."

The company is making plans to ensure the well-being of their patients, said MacNeil, and is committed to keeping the four Niagara clinics open--one each in Niagara Falls, Welland, St. Catharines and Vineland -with help "from other partners." They also plan to continue to provide service to the highest-needs patients, she said. "We're working with our community partners to have a contingency plan for every patient, based on their level of care needs. We're going through the process and seeing what the available resources are for their care," said MacNeil. A press release from CarePartners says the company has been committed to the bargaining process for the last 18 months, and is ready to return to the bargaining table. Talks broke off, the press release says, when the union insisted on compensation and employment demands that would be the equivalent of those provided to nurses in hospitals -- while publicly -- funded reimbursement rates for the services CarPartners provide have been frozen since 2009, the union's demand amounts to a more than 10% compensation increase. The reimbursement rate freeze is expected to continue throughout 2015, the press release says. "Compensation adjustments have been issued during this timeframe, however, the amount of the adjustments has been restricted as a direct result of the rate freeze within the sector," MacNeil said.

St. Albert physician Dr. Darryl LaBuick said while a bit more money for home care will help the situation, it barely scratches the surface in addressing the biggest issues facing healthcare in Canada. "We've got a huge increasing requirement for seniors care. We look at home care, we look at long-term care, we look at assisted living care, palliative care," he said. "We look at all those areas nobody has looked at closely from a political point of view to address some of the issues." The importance of home care is something stressed by Dr. Kim Fraser, a nursing professor at the University of Alberta and expert on the topic.

She said while seeing the commitment to improve home care in the province is a step in the right direction, simply throwing more money at the problem won't be enough. Instead, we've got to rethink how home care in Canada is provided. "Co-ordinated home care programs first came into effect in the late '70s and 1980s in Canada, and our approach to home care has not changed since that time," she said. "It's really kind of episodic, targeted, taskspecific care rather than a more comprehensive integrated care approach." So rather than simply having more home-care aides providing this kind of task-oriented service to patients in their home, we should look at providing a higher level of care to patients with more complex needs.

"We have got just so many more patients going into that system," she said. "I think funding will help the growing home care problem, and will help provide, perhaps, more professional nursing services from RNs and LPNs in the community." Alberta Health Minister Sarah Hoffman said she was pleased to see the commitment to home care on the federal agenda, noting it was one of the main pieces of the NDP platform with respect to the healthcare system. "Home care is certainly one of the pieces we're focusing our effort on as a goveRNment, and I look forward to working with the new federal goveRNment to make that a reality," she said. When pressed for specific details about what form home care may take, she said she couldn't talk about specifics until they're released as part of the provincial budget next week.

"The pillars of the platform should be reflected in the work we're doing," Hoffman said. LaBuick also identified the importance of a national drug strategy that would cover the cost of prescriptions for all Canadians. Seniors still must pay a portion of prescription drug costs, and many young adults without health benefit plans are left in a position where they must pay the full cost or simply go without; it's something he's seen in his own practice. "We see young folks that don't have a good prescription plan, or any prescription plan," he said, "And the Blue Cross plan doesn't cover everything either, so there's gaps within that system, too."

It's a concern echoed by Friends of Medicare director Sandra Azocar, who spoke with the Gazette prior to the election and said a national drug plan was high on her organization's agenda. She expressed concern that the Trans-Pacific Partnership, a trade deal negotiated by the previous government behind closed doors that has yet to be approved by Parliament, could make it more difficult to get cheaper generic drugs. "We see that as having a negative impact for generics to be available in the market, and people will pay significantly more for drugs," she said. "I don't think medicine should be a luxury, it should be available for all people who need it. These are huge concerns we have." Hoffman said bringing down the cost of prescription drugs is something she's heard is important to Albertans, but is also significant within her own ministry when it comes to budgeting. She said a provincial prescription drug plan is something worth considering, but it's not going to happen in the near future.

"I think it's a great long-term objective, but in the short-term I need to address the immediate pressures of drug costs," she said. "I think we can find ways to do bulk buying and find other efficiencies in a pan-Canadian strategy, and look at other partnerships in taking it further so we can maximize those savings and pass those savings on for an increased benefit to all Albertans." Health Accord Azocar identified the need to renew the Canada Health Accord as an important component of what the federal government must do to support healthcare in the country.

"We need to go back to the level of leadership in our healthcare system for it to be functional all across the country," she said. "That's not something we've seen coming from some of the parties." The Liberal platform includes a commitment to renew the waccord, and to include a long-term funding agreement. This is a crucial element, Azocar noted, because in tough economic times federal funding in health care tends to decrease to the detriment of Canadians. "People don't stop needing health care when the economy is down, in fact it's the reverse," she said. "Studies have shown people need more services when the economy is down, so it's a situation that doesn't play well for the sustainability and the long-term planning that health care needs across the country."

Hoffman said she's unsure what negotiating a new accord might look like, as she hasn't been through the process before, but said it's something she looks forward to working on with the federal government. "We were elected not too long ago and they were elected more recently, and I think Albertans deserve to have the very best public health-care system," she said. "I look forward to working with the federal government to make that a reality." Elephant in the room One element of the discussion around health care that is absent and has been for quite some time, LaBuick suggested, is the "elephant in the room" of increasing private delivery as a way to reduce the budget impact of health care. "The minute we start to talk about it, they catastrophize the whole conversation," he said. "The reality is we need to talk about it because we simply can't afford it."

He noted roughly 30 per cent of health care in Canada is already provided privately - things like dental, vision, psychology, and private insurance plans. Furthermore European countries that blend public and private have better outcomes. LaBuick suggested the way forward is to look to European models that provide universal health care with a blend of public and private delivery - many of which have better outcomes at a lower cost than the Canadian model. He's not optimistic, however, that a federal Liberal government or provincial NDP government will engage in that discussion.

We have all of these areas that are private, but nobody talks about it," he said. "Nobody talks about a strategy around how it can benefit all citizens, for the betterment of everybody."