Group items tagged

the 2020 Budget allocated $3.0 billion to its standard contingency funds in 2020-21, which grow over the 2021-22 to 2022-23 period and are much larger than usual. The government has yet to clearly indicate the specific purpose of the sharp increase in these funds after the pandemic.

net debt as a share of GDP is projected to reach 50 per cent by 2025-26 in the absence of policy changes.

This could make the province more vulnerable to unexpected interest rate increases in the future. However, the cost of financing the large increase in debt will be manageable over the outlook if interest rates remain near historic lows, as currently expected.

a second and larger wave of COVID-19 infections in the fall prompted renewed restrictions across the province, significantly slowing the pace of Ontario’s economic recovery late last year and early in 2021.

As the province recovers from the COVID-19 pandemic and the economy rebounds, the budget deficit is expected to remain elevated at $30.7 billion in 2021-22 and improve modestly to $24 billion in 2022-23. Beyond 2022-23 the FAO projects that the deficit will stabilize at around $16 billion in the absence of further policy changes.

As the pandemic continues, total revenues are expected to decline sharply in 2020-21 by $4.5 billion, a decline of 2.9 per cent.

The drop in overall revenues results from a substantial $10.3 billion decline in tax revenues which is partially offset by a significant $8.0 billion increase in transfers from the federal government, largely consisting of one-time COVID-related support.

Despite the economic rebound, 2021-22 revenues are expected to remain largely unchanged as the increase in tax revenues is offset by a reduction in federal transfers. As the economy is more fully reopened, revenue growth picks up in 2022-23.

Program spending growth in key sectors will not keep pace with demand for public services

The 2020 Budget allocated $3.0 billion to its standard contingency funds in 2020-21, significantly above the usual size and in addition to the temporary COVID-19 funds. Over the next two years, the allocation to the standard contingency funds will increase even further. While contingency funds are maintained to manage expense risks, the government has not clearly indicated the purpose of the sharp increase in these funds after the pandemic. Importantly, if these contingency funds are not used for new programs or future unforeseen events, they may be used to reduce deficits.

Assuming vaccines are distributed to the general population over the course of 2021 and that social distancing and select restrictions remain in place until early 2022, Ontario real GDP is expected to rise by 3.9 per cent in 2021 and 4.5 per cent in 2022

In Ontario, the Fiscal Sustainability, Transparency and Accountability Act, 2019 (FSTAA) requires that when the budget is in deficit, the Province must develop a fiscal recovery plan that specifies how and when the budget will be balanced. The government committed to present a multi-year fiscal recovery plan in the 2021 Ontario budget, to be delivered by March 31, 2021.

Net debt is expected to rise sharply by $41.7 billion, to $395 billion in 2020-21, pushing the net debt-to-GDP ratio up to 46.7 per cent. Large and continued deficits add to debt and raise the net debt-to-GDP ratio over the outlook, which reaches almost 50 per cent by 2022-23 – 10 percentage points higher than the pre-pandemic ratio.

However, the cost of financing the large increase in provincial debt is expected to be manageable over the medium term. As a share of revenue, interest on debt is expected to rise to 8.2 per cent in 2020-21, as revenues decline due to the COVID-19 pandemic. As the economy and provincial revenues rebound, interest payments as a share of revenues are expected to decline to 7.9 per cent by 2022-23, similar to its pre-pandemic share.

This outcome is largely due to the expectation that interest rates will remain near historic lows over the outlook. However, the significant increase in debt leaves the province more vulnerable to unexpected interest rate increases in the future.

Given high COVID-19 caseloads and hospitalizations, the FAO expects stringent restrictions will remain in place through much of the winter, followed by a slow reopening during the rest of the year as vaccinations become increasingly available. As a result, the projected rebound in economic activity in 2021 will be more muted than previously expected.

The FAO projects Ontario real GDP will drop by 5.9 per cent in 2020, the largest annual decline in economic output on record.

In the January 2021 Monetary Policy Report, the Bank affirmed its intention to continue monetary policy support and hold the rate at 0.25 per cent until the Bank’s annual inflation target of 2 per cent is achieved.

According to the Bank’s projections, a slow recovery and the impact of the pandemic are expected to dampen inflation until 2023, signalling that short-term interest rates are likely to remain low over the next two years.

Over the 2023 to 2024 period, Ontario’s economy is expected to return to more normal conditions, with average real GDP growth of 1.9 per cent.

During the pandemic shutdowns, Ontario employment fell by a record 1.1 million jobs (or 15.2 per cent) from February to May 2020. As the economy reopened through last summer, employment rebounded strongly, rising by 729,100 since May 2020 and recovering almost two-thirds of the jobs lost during the first wave of the pandemic. Despite these gains, Ontario employment remained down by 405,600 jobs (or 5.4 per cent) in January 2021 compared to the pre-pandemic levels in February 2020.[5] The pace of monthly job gains has slowed noticeably as the second wave of COVID-19 infections and renewed partial restrictions caused job losses in some sectors in late 2020 and early 2021.

On an average annual basis, Ontario’s employment declined by 355,300 jobs (-4.8 per cent) in 2020, while the unemployment rate jumped to 9.6 per cent, up from 5.6 per cent in the previous year. As the economy improves through 2021, job growth will rebound, but the level of employment is not projected to reach its pre-pandemic peak until 2022. The unemployment rate will gradually trend down to pre-pandemic levels towards the end of the outlook.

Corporate profits are projected to record a sharp 12.0 per cent decline in 2020, even as businesses adapted their operation to pandemic shutdown measures. Over the next two years, corporate profits are expected to recover strongly with average growth of 8.0 per cent as businesses increasingly return to more normal levels of activity. Overall, nominal GDP is expected to decline by 5.2 per cent in 2020, followed by a rebound of 5.4 and 6.0 per cent growth in 2021 and 2022, respectively.

Large ongoing budget deficits projected for Ontario

The FAO projects Ontario’s budget deficit will increase from $8.7 billion in 2019-20 to a record $35.5 billion in 2020-21. As the province recovers from the COVID-19 pandemic and the economy rebounds, the budget deficit is expected to remain elevated at $30.7 billion in 2021-22 and improve modestly to $24 billion in 2022-23. These projected deficits are broadly consistent with the government’s deficit forecast in the 2020 Ontario Budget.

Total revenues are projected to fall by $4.5 billion in 2020-21 to $151.6 billion, a decline of 2.9 per cent. The drop in revenues results from a substantial $10.3 billion (9.5 per cent) decline in tax revenues[7] and a $2.2 billion decrease in ‘other’ revenues, notably lower income from Government Business Enterprises[8]. These revenue declines are partially offset by a significant $8.0 billion (31.3 per cent) increase in transfers from the federal government, largely consisting of one-time COVID-related support.[9]

Based on the 2020 Budget spending plan, Ontario’s program spending in 2020-21 is projected to be $174.6 billion, or $22.3 billion higher than in 2019-20. This 14.7 per cent rise in program spending is the largest increase since 2009-10, with over 70 per cent of the total increase driven by temporary COVID-19 related spending.

Province plans to slow base program spending growth Based on the 2020 Budget’s medium-term outlook, total program spending growth is projected to moderate over the 2021-22 to 2022-23 period as temporary COVID-19 related measures are gradually phased out. Specifically, COVID-19 related spending is projected to decline from $16.5 billion[10] in 2020-21 to $2.8 billion in 2022-23. Over this period, base program spending growth (excluding COVID-related expenditures) is projected to slow from 4.2 per cent in 2020-21 to 2.7 per cent in 2022-23.

Program spending growth in key sectors will not keep pace with demand for public services

Based on the 2020 Budget, over the next two years planned program spending growth in key sectors will not keep pace with the underlying growth in the demand for public services, which is driven by factors such as population growth and price inflation (Figure 4-4).

In the health sector, base spending is projected to grow at an average annual pace of 2.9 per cent, below the projected growth of 4.6 per cent in key cost drivers of the health care sector, such as health inflation, population growth and aging. Education sector spending is projected to grow at an average annual pace of 1.6 per cent, slower than the 2.9 per cent annual growth projected for the number of school-age children and price inflation. Similarly, planned program spending growth in children’s and social services, justice, and postsecondary education sectors will be below the average projected growth in their underlying demand drivers over the 2021-22 to 2022-23 period.

Growth in ‘Other Programs’ spending driven by significant increase to standard contingency funds ‘Other Programs’ includes a variety of ministries[11] along with the standard operating and capital contingency funds, which are regular prudence measures incorporated into the government’s budget. According to the 2020 Budget, the government allocated $3.0 billion for its standard contingency funds in 2020-21,[12] significantly above the usual size of the funds,[13] and also in addition to the dedicated COVID-19 contingency funds. While the standard contingency funds are maintained to manage expense risks, the government has yet to indicate the specific purpose of the sharp increase in these funds. Importantly, if these contingency funds are not used for new initiatives or to respond to future extraordinary events, the unused portion of the funds would be available to reduce future deficits.[14]

Over the 2021-22 to 2022-23 period, the allocation to these standard contingency funds will increase even further, accelerating the growth in ‘Other Program’ spending to an average annual pace of 9.5 per cent, significantly higher than the planned growth in all the key sectors. Excluding contingency funds, ‘other’ base program spending is projected to grow at 4.4 per cent annually, 1.1 percentage point above the pace of population growth and inflation.

The FAO projects a record budget deficit of $35.5 billion (or 4.2 per cent of GDP) in 2020-21, as the COVID-19 pandemic resulted in both a sharp decline in revenues and a significant increase in program spending. Importantly, the government could report a smaller budget deficit for 2020-21 than the FAO’s projection if it does not allocate the remaining contingency funds to specific programs or spends less than planned.[15]

Net debt is expected to rise sharply by $41.7 billion, to $395 billion in 2020-21. The substantial increase in net debt results in a large jump in the net debt-to-GDP ratio, which is expected to rise to 46.7 per cent in 2020-21. Large and continued deficits lead to increasing levels of debt and a rising net debt-to-GDP ratio over the outlook, which reaches almost 50 per cent by 2022-23 – about 10 percentage points higher than the pre-pandemic ratio.

In the absence of policy changes, the FAO projects Ontario’s budget deficits to remain steady in the range of $16 billion in the extended projection. These ongoing deficits reflect the starting point of an $8.7 billion deficit in 2019-20 (before the onset of the COVID-19 crisis), the lasting economic and fiscal impacts of the pandemic going forward, as well as the province’s aging population, which contributes to both slower economic growth and higher demands for government spending.

To provide an estimate of the extent of ongoing revenue increases or spending cuts that would be required to balance the budget, the FAO constructed a hypothetical scenario under which the budget is balanced over a five-year period. In this “balanced budget scenario,” a total of $16 billion of revenue increases and spending cuts (in equal measure) are phased in over five years to reach a balanced budget by 2025-26.

If the government were to permanently increase personal income tax revenue by 10 per cent or around $500 per tax filer, starting in 2021-22, the budget deficit would improve by $3.7 billion in the first year and by $4.9 billion by 2025-26. For federal transfers, if the annual growth rate of the Canada Health Transfer or the Canada Social Transfer were to increase by 1 percentage point over the projection, the budget deficit would decrease by 1.0 billion or $0.5 billion respectively by 2025-26. For expenditure policy, if the government were to decrease the growth rate of program spending by 0.5 percentage points in each year beginning in 2021-22, the budget deficit would decrease by $4.7 billion by 2025-26. Given the FSTAA requirements for a balanced budget, these estimated budget sensitivities are intended to inform the debate around the government’s policy choices.

The increased revenue forecast is primarily due to higher than projected taxation revenue attributable to stronger than expected nominal gross domestic product (GDP) growth in 2021 and higher net tax assessments for 2020 and prior years. Nominal GDP is estimated to have increased 11.9 per cent in 2021, higher than the prudent 2021 Ontario Economic Outlook and Fiscal Review nominal GDP growth planning assumption of 9.0 per cent.

Ontario's real GDP increased 1.4 per cent in the third quarter of 2021, after a 1.2 per cent decline in the second quarter. As of the third quarter, Ontario's real GDP was 1.2 per cent below the fourth quarter of 2019.

Ontario's net debt-to-GDP ratio is projected to be 40.8 per cent in 2021–22, 8.0 percentage points lower than the 48.8 per cent forecast in the 2021 Budget and 2.6 percentage points lower than projected in the 2021 Ontario Economic Outlook and Fiscal Review.

The government recognizes that economic uncertainty and challenges, including the rising cost of living, continue.

The Province's 2021–22 deficit is projected to be $13.1 billion — $20.0 billion lower than the outlook published in the 2021 Budget and $8.4 billion lower than projected in the 2021 Ontario Economic Outlook and Fiscal Review.

Revenues in 2021–22 are projected to be $176.7 billion — $22.6 billion higher than forecast in the 2021 Budget and $8.0 billion higher than projected in the 2021 Ontario Economic Outlook and Fiscal Review. The increased revenue forecast is primarily due to higher than projected taxation revenue attributable to stronger than expected nominal GDP growth in 2021 and higher net tax assessments for 2020 and prior years.

Program expense is projected to be $175.8 billion — $2.8 billion higher than the 2021 Budget outlook. Since the 2021 Ontario Economic Outlook and Fiscal Review, the government has made $2.3 billion in additional investments, primarily in health care and supports for businesses and workers impacted by public health restrictions to blunt the spread of Omicron. After offsetting the cost of these investments against existing contingencies and accounting for ministry underspending, program expense is projected to be $0.4 billion lower relative to the outlook presented in the 2021 Ontario Economic Outlook and Fiscal Review.

With the release of the 2021 Ontario Economic Outlook and Fiscal Review, the Time-Limited COVID-19covid 19 Fund had a $2.7 billion allocation to respond to the ongoing uncertainty related to the pandemic and the future pace of economic recovery. In response to the rise of the Omicron variant and the resulting necessary public health restrictions, additional support has been provided through the Time-Limited COVID-19covid 19 Fund. After the drawdowns reported in both the 2021 Ontario Economic Outlook and Fiscal Review and the 2021–22 Third Quarter Finances, the balance of this Fund is $500 million for the remainder of the fiscal year.

With the release of the 2021–22 Third Quarter Finances, the reserve has been maintained at $1.0 billion, which can be used to address any unforeseen events that could arise before the fiscal year-end.

The International Monetary Fund projects global real GDP to rise by 5.9 per cent in 2021, followed by 4.4 per cent growth in 2022. U.S. real GDP increased by 5.7 per cent in 2021 and, according to the Blue Chip Economic Indicators survey, forecasters expect U.S. real GDP to increase by 3.9 per cent in 2022.

Corporations Tax revenue increased by $5.3 billion, mainly due to higher 2020 and prior year tax assessments;

Personal Income Tax revenue increased by $1.3 billion, mainly due to higher compensation of employees growth for 2021, reflecting growth in employment, partially offset by weaker 2020 and prior year tax assessments;

Employer Health Tax increased by $529 million, mainly due to higher compensation of employees growth for 2021, reflecting growth in employment;

$1.3 billion in additional funding to support hospitals during the COVID-19covid 19 pandemic, including expenses such as personal protective equipment, additional staff and Infection Prevention and Control measures, as well as funding to support the rollout of COVID-19covid 19 vaccines;

$164 million to help long-term care homes prevent and contain the spread of COVID-19covid 19, including increased staffing supports and purchasing additional personal protective equipment supplies;

$108 million to train up to 8,200 new personal support workers (PSWs) for high-demand jobs in Ontario's health and long-term care sectors to address the personal support workforce shortage;

The Province's cost of borrowing has, however, increased to 2.1 per cent, higher than the 1.9 per cent forecast in the 2021 Budget and the 2021 Ontario Economic Outlook and Fiscal Review.

Despite this increase, lower forecast long term borrowings for this year have allowed the interest on debt projection to remain unchanged, at $13.0 billion.

In order to maintain continued flexibility during this uncertain time, as the 2021–22 fiscal year unfolded, the Province allocated $2.2 billion to the Time-Limited COVID-19covid 19 Fund in 2021–22 as part of the 2021–22 First Quarter Finances, with an additional $500 million increase to this Fund announced in the 2021 Ontario Economic Outlook and Fiscal Review. After all projected drawdowns reported in the 2021–22 Third Quarter Finances, the remaining balance of the Time-Limited COVID-19covid 19 Fund for 2021–22 is $500 million.

ntario's real GDP increased by 1.4 per cent in the third quarter of 2021, following a decline in the second quarter.

Since the release of the 2021 Ontario Economic Outlook and Fiscal Review, the government has invested an additional $2.3 billion, primarily in the health care system and supports for businesses and workers. Highlights include: $1.3 billion in additional funding to support hospitals with personal protective equipment, additional staff and Infection Prevention and Control measures, as well as funding to support the rollout of COVID-19covid 19 vaccines;

The Ministry of Finance is estimating that Ontario real GDP increased 4.4 per cent in 2021, up slightly from the 2021 Ontario Economic Outlook and Fiscal Review real GDP growth planning assumption of 4.3 per cent. Ontario nominal GDP is estimated to have increased 11.9 per cent in 2021, higher than the prudent 2021 Ontario Economic Outlook and Fiscal Review nominal GDP growth planning assumption of 9.0 per cent.

The private-sector average forecast footnote 1 [1] for Ontario real GDP growth in 2022 is 4.2 per cent, lower than the private-sector average increase of 4.6 per cent forecast at the time of the 2021 Ontario Economic Outlook and Fiscal Review. The private-sector average forecast for Ontario nominal GDP growth in 2022 is 7.0 per cent, higher than the private-sector average forecast increase of 6.7 per cent at the time of the 2021 Ontario Economic Outlook and Fiscal Review.

Ministry Expense 2021–22: 2021 Budget 2021–22: Current Outlook 2021–22: In-Year Change

Health (Total) 64,016.7 64,093.5 76.8 COVID-19 Health Response17 5,144.1 6,656.1 1,512.0

Long-Term Care (Total)23 5,764.0 5,886.6 122.5

The Province spent $76.9 billion over the first two quarters of 2021-22, which was $4.3 billion (5.3 per cent) less than planned.

In the health sector, the Province spent or reallocated $441 million (16.6 per cent) of the $2.7 billion budget for the COVID-19 Response program.

Spending over the first two quarters of 2021-22 was $2.6 billion (3.5 per cent) more than during the same period in 2020-21. Highlights include:

Health spent $3.1 billion (9.8 per cent) more in the first two quarters of 2021-22 compared to 2020-21, including higher spending for population and public health programs ($885 million), Ontario Drug Programs ($828 million), payments to physicians ($456 million), and long-term care homes operations ($373 million) and capital investments ($333 million).

The Province started the 2021-22 fiscal year with a total of $2.1 billion in unallocated funds in the Contingency Fund. After accounting for the $709 million in transfers from the Contingency Fund in the first and second quarters, the remaining balance in the Contingency Fund, as of September 30, 2021, was $1.4 billion. On November 4, 2021, the Province tabled Supplementary Estimates, which created the Time-Limited COVID-19 Fund, with a starting balance of $2.7 billion, and also topped up the Contingency Fund with an additional $0.3 billion. These changes, along with any third quarter transfers from the Contingency Fund and the new Time-Limited COVID-19 Fund, will be reflected in the FAO’s Q3 Expenditure Monitor report.

Health: $15 million increase, including: $97 million increase for Information Technology Services – Health Cluster (Vote-Item 1413-1) to support COVaxON, the Province’s vaccine administration and inventory management system. $21 million increase for the Long-Term Care Homes Program (Operating) (Vote-Item 4502-1) to support the operation of long-term care homes. $107 million decrease for Population and Public Health (Vote-Item 1406-4), as the Province transferred funds from the COVID-19 Response program to Information Technology Services – Health Cluster ($97 million) and to Wastewater Monitoring and Public Reporting ($11 million) within the Ministry of the Environment, Conservation and Parks, to support COVID-19-related measures.

Table 2: 2021-22 spending by sector, as of September 30, 2021, $ millions Note: Figures exclude spending on some assets and additional spending by the broader public sector organizations controlled by the Province (hospitals, school boards and colleges), the Province’s agencies and the legislative offices. Source: FAO analysis of the 2021-22 Expenditure Estimates and information provided by Treasury Board Secretariat. Sector Revised 2021-22 Spending Plan Planned Spending at end of Q2 Actual Spending at end of Q2 Actual vs. Planned at end of Q2 Actual vs.

Health 71,204 35,033 34,059 -974 -2.8%

Health sector spending: $974 million (2.8 per cent) below plan, including: $148 million above plan in Programs and Administration (Vote-Item 1416-2), which funds Ontario Health programs and administration (Cancer Treatment and Screening, Digital Health, Regional Coordination Operations Support, Organ and Tissue Donation and Transplantation Services, etc.). The above plan spending was led by the Digital Health program, which, as of September 30, had spent 90 per cent of its $205 million budget. $138 million below plan in Health Capital (Vote-Item 1407-1), which provides capital funding to hospitals and other health care facilities. $266 million below plan in Ontario Health Insurance (Vote-Item 1405-1), which administers payments to physicians. $604 million below plan in Population and Public Health (Vote-Item 1406-4), which includes the $2.7 billion COVID-19 Response program.[12] In the second quarter, the Province withdrew $107 million from the COVID-19 Response program and transferred the funding to Information Technology Services – Health Cluster ($97 million) and to Wastewater Monitoring and Public Reporting ($11 million) within the Ministry of the Environment, Conservation and Parks, to support COVID-19-related measures. In addition, the Province spent $334 million directly from the program’s budget. These actions result in remaining funds, as of September 30, 2021, of $2.2 billion in the COVID-19 Response program, which represents a slower pace of spending than the Province anticipated at the start of the fiscal year. (The Ministry of Health noted to the FAO that spending in the COVID-19 Response program was slower than anticipated due to lower than planned COVID-19 testing volumes and timing differences between when COVID-19 lab tests occur and when the tests are reimbursed through the COVID-19 Response program.)

Table 3: Spending through the end of the second quarter by sector, 2021-22 vs. 2020-21, $ millions Note: Figures exclude spending on some assets and additional spending by the broader public sector organizations controlled by the Province (hospitals, school boards and colleges), the Province’s agencies and the legislative offices. Source: FAO analysis of the 2021-22 Expenditure Estimates and information provided by Treasury Board Secretariat. Sector 2021-22 Spending at end of Q2 2020-21 Spending at end of Q2 2021-22 vs. 2020-21 2021-22 vs. 2020-21 (%) Health 34,059 31,009 3,051 9.8%

The health sector spent $3,051 million (9.8 per cent) more in the first six months of 2021-22 compared to 2020-21, largely due to higher spending for: Population and Public Health ($885 million); Ontario Drug Programs ($828 million); payments to physicians ($456 million); the operation of long-term care homes ($373 million) and capital investments ($333 million); and Ontario Health programs and administration (Cancer Treatment and Screening, Digital Health, Regional Coordination Operations Support, Organ and Tissue Donation and Transplantation Services, etc.) ($254 million);

offset by lower spending on: Health Capital (-$165 million); and the operation of hospitals (-$188 million).

Status of Unallocated Funds The Province started the 2021-22 fiscal year with a total of $2.1 billion in unallocated funds in the Contingency Fund. Unallocated funds cannot be spent directly by the Province but must be transferred to government programs through Treasury Board Orders. Through the first two quarters of 2021-22, the Province transferred a net $709 million from the Contingency Fund to various programs, resulting in a remaining Contingency Fund balance as of September 30, 2021 of $1.4 billion. In the government’s 2021-22 First Quarter Finances (released on August 12), the Province announced that an additional $2.2 billion in unallocated funds would be made available through a new program called the Time-Limited COVID-19 Fund.

In the third quarter, on November 4, 2021, the Province tabled Supplementary Estimates, which created the Time-Limited COVID-19 Fund, with a starting balance of $2.7 billion, and also topped up the Contingency Fund with an additional $0.3 billion. These changes, along with any third quarter transfers from the Contingency Fund and the Time-Limited COVID-19 Fund, will be reflected in the FAO’s Q3 Expenditure Monitor report.

Alternatively, the Province could make program cuts or changes to its expansion commitments to achieve its health sector spending plan targets.

the FAO projects a shortfall of 33,000 nurses and PSWs. These nurse and PSW shortages will jeopardize Ontario’s ability to sustain current programs and meet program expansion commitments.

challenges are expected to persist across Ontario’s health care system.

First, given that there is a $21.3 billion health sector funding shortfall, the Province has not allocated sufficient funding to ensure that the 4,500 additional hospital beds can be operated.

In total, the FAO projects that the Province’s health sector spending plan has a net funding shortfall over the six-year period from 2022-23 to 2027-28 of $21.3 billion.

The FAO’s spending forecast assumes wage growth is consistent with existing collective agreements and, for new collective agreements, historical long-term average growth in wages. However, given recent elevated inflation, there is the potential for above-average wage settlements, which would lead to higher than projected spending.

On November 29, 2022, the Ontario Superior Court of Justice ruled that Bill 124, which limits base salary increases for most provincial employees to one per cent per year for a period of three years, was in violation of the Canadian Charter of Rights and Freedoms and was declared to be void and of no effect. The government has appealed this decision. If the government is unsuccessful in its appeal, then provincial spending on wages would be higher than projected in the FAO’s forecast.

If successful, the Province’s measures would add 4,500 new hospital beds from 2019-20 to 2027-28 and free up 2,500 existing beds occupied by ALC patients, for a total increase in available capacity of 7,000 hospital beds. However, the FAO expects that it is unlikely that the Province will achieve the 7,000 hospital beds target under current policies.

Based on current program design and announced commitments, the FAO projects that health sector spending will grow at an average annual rate of 3.6 per cent between 2021-22 and 2027-28, reaching $93.8 billion in 2027-28. In contrast, the funding allocated by the Province in the 2022 Ontario Budget and the 2022 Fall Economic Statement (FES) grows at an average annual rate of 2.5 per cent, reaching $87.8 billion by 2027-28.

New funding could be added to the health sector from a combination of the contingency fund,[5] new federal health transfers or new incremental program spending. On February 7, 2023, the federal government announced changes to health funding arrangements which, as of the writing of this report, the FAO estimates will result in new incremental federal health transfers to the Province totalling $10.9 billion from 2023-24 to 2027-28. If the Province uses all of the $10.9 billion in incremental federal health transfers to increase funding for the health sector spending plan, then the FAO estimates that this new funding would cover approximately half of the health sector funding shortfall identified by the FAO.

Finally, even if the Province achieves its plan to increase available hospital capacity by 7,000 beds by 2027-28, the FAO projects that Ontario will still be 500 beds short of the estimated 7,500 beds needed just to serve the growth in demand for hospital services from Ontario’s growing and aging population. This suggests that without additional measures, Ontario will have less available hospital capacity relative to need in 2027-28 than in 2019-20.

Despite these significant investments, the FAO estimates that there will still be a slight decline in home care and long-term care capacity relative to need compared to 2019-20. This is due to high growth in the number of Ontario seniors over the forecast period, which will significantly increase demand for home care and long-term care services. For home care, the number of nursing and personal care hours per Ontarian aged 65 and over will be about the same in 2024-25 as it was in 2019-20. For long-term care, the number of beds per 1,000 Ontarians aged 75 and over will decline slightly from 71 in 2019-20 to 70 in 2027-28.

Despite the Province’s $858 million investment over three years from 2020-21 to 2022-23, the number of surgeries performed has not returned to pre-pandemic levels. Looking only at months not affected by elective surgery pauses, the average number of surgeries performed in each month from 2020 to 2022 was significantly lower than in 2019. Average monthly surgeries performed were 14 per cent lower in 2020, 12 per cent lower in 2021 and eight per cent lower in 2022 (as of September 2022).

To achieve its surgery waitlist target, the rate of decline in the waitlist would need to be significantly faster than what the Province has achieved up to September 2022.

the Province has yet to record any sustained reduction in the number of these patients waiting for surgery.

As of September 2022, the surgery waitlist had 107,000 long-waiters, which was the highest number recorded since the start of the pandemic. Consequently, without additional measures, the Province will not achieve its goal of reducing the number of patients on the surgery waitlist classified as long-waiters to the pre-pandemic level of 38,000.

As patient volumes in emergency departments have returned to near pre-pandemic levels, emergency department wait times have increased significantly. In 2022-23, the average length of stay in an emergency department for patients admitted to hospitals was 20.9 hours. This is 34 per cent higher than wait times over the five-year period prior to the COVID-19 pandemic and the longest average wait time recorded in over 15 years.

Additionally, as of the writing of this report, there have been at least 145 unplanned emergency department closures in Ontario in 2022. Prior to the emergency department closures in 2022, the FAO is aware of only one unplanned emergency department closure since 2006 due to a lack of doctors.

Emergency department closures are primarily an issue in smaller population centres, while the longest emergency department wait times are more commonly found in hospitals in urban areas. Ontario hospitals have identified a lack of available staff, including nurses and physicians, as the key issue causing longer emergency department wait times and closures.

Overall, while the Province’s measures do address physician shortages in rural emergency departments, which contributes to emergency department closures, the measures do not provide for a sustained increase in emergency department staffing across the Province. From 2017-18 to 2019-20, emergency department wait times were significantly lower despite higher patient volumes. As a result, Ontario’s success in addressing emergency department strain depends on the success of the Province’s measures for the fifth area of focus, which is expanding the health sector workforce.

Second, to achieve its target, the Province must permanently free up all 2,000 beds occupied by ALC patients waiting for a long-term care placement as of September 2022. This will be challenging given that there are over 39,000 Ontarians on the waitlist for long-term care and the Province must effectively reduce time to placement from hospitals from a median of 39 days to zero.

The Province is implementing a number of measures to increase the supply of nurses and personal support workers, including measures targeting pay, training and regulatory barriers. These measures have been announced across several policy documents.[4]

Based on the FAO’s analysis, the health workforce policy measures announced by the Province, along with natural growth, are expected to add 53,700 nurses and PSWs over the six-year period to 2027-28. Nevertheless, this increase in nurses and PSWs will not be sufficient to address current staffing shortages and meet Ontario’s commitments to expand care in hospitals, long-term care and home care, with an expected shortfall of 33,000 nurses and PSWs in 2027-28.

Failure to address the projected shortfall in nurses and PSWs will result in the Province being unable to meet its expansion commitments in hospitals, home care and long-term care. The shortfall will also have additional impacts on health sector service levels, including in hospital emergency departments, the waitlist and wait times for surgeries, and average hours of direct care provided to long-term care residents.

This report reviews the Province’s health sector spending plan in the 2022 Ontario Budget, the 2022-23 Expenditure Estimates, and the 2022 Ontario Economic Outlook and Fiscal Review (known as the Fall Economic Statement or FES). Health sector spending includes the combined spending by the Ministries of Health and Long-Term Care.

For the current fiscal year, 2022-23, the FAO estimates that the Province has allocated $1.3 billion in excess funds that are not required to support existing programs and announced commitments.

However, beginning in 2023-24, the FAO projects health sector funding shortfalls, starting at $1.6 billion in 2023-24 and growing to $6.0 billion in 2027-28.

The FAO projects that in order to return to pre-pandemic vacancy rates and meet government program expansion commitments in hospitals, home care and long-term care, Ontario needs 86,700 additional nurses and personal support workers by 2027-28. This represents an approximately 26 per cent increase in nurses and a 45 per cent increase in personal support workers employed in these sectors.

In 2022-23, the FAO’s projection for health sector spending is $1.3 billion lower than the Province’s spending plan. This is primarily due to the FAO’s lower projected COVID-19-related spending. However, by 2024-25, the FAO’s spending projection is $4.6 billion higher than the Province’s. Most of the spending gap is in the hospitals and OHIP (physicians and practitioners) program areas, which are the two largest health sector spending categories.[6] Overall, the FAO projects 3.1 per cent average annual spending growth between 2021-22 and 2024-25. In contrast, the Province projects slower growth, averaging 1.1 per cent from 2021-22 to 2024-25.

Recovery Period: The Province plans to increase annual health sector spending by an average of 3.9 per cent per year over the recovery period from 2024-25 to 2027-28. In comparison, based on the FAO’s review of health sector programs and announced commitments, the FAO projects spending will grow at an average annual rate of 4.2 per cent over the same period. As a result, the FAO projects that health sector spending will be $6.0 billion higher in 2027-28 compared to the government’s forecast in the 2022 budget.

For the period between 2021-22 and 2027-28, the FAO projects health sector spending will grow at an average annual rate of 3.6 per cent. The FAO projects that spending on the two largest program areas, hospitals and OHIP (physicians and practitioners), will grow by average annual rates of 3.0 and 4.1 per cent, respectively. Ontario public drug programs spending is projected to grow by an average of 5.7 per cent per year, followed by mental health and addictions programs (5.4 per cent) and community programs (5.0 per cent). The FAO projects that the long-term care program area will have the highest average annual growth rate over the six-year period, at 8.3 per cent, while other programs will decline by an average of -1.2 per cent per year due to the expiry of time-limited COVID-19-related spending. Lastly, spending on health capital is projected to grow at 3.1 per cent per year.

Given that there were significant time-limited investments related to the COVID-19 pandemic in 2021-22, and that the COVID-19 pandemic impacted service levels in many areas of the health sector, the FAO has also provided growth rates from 2019-20 to 2027-28 to provide a better indication of base health sector program spending growth. From 2019-20 to 2027-28, the FAO estimates base health sector spending will grow at an average annual rate of 5.0 per cent.

Program Area 2021-22 Actual Spending ($ billions) 2027-28 Projected Spending ($ billions) Average Annual Growth Rate (%) 2021-22 to 2027-28 Average Annual Growth Rate (%) 2019-20 to 2027-28 Hospitals 26.4 31.5 3.0 4.0

The two most significant factors behind the FAO’s spending projection are assumptions for hospital employee wage growth and hospital capacity.

The largest component of hospitals spending is compensation, which comprises approximately 60 per cent of total hospital operating expenses.

From 2022-23 to 2024-25, the FAO estimates hospital employee wages will grow at an average annual rate of 1.5 per cent. This growth rate is below the historical average due to the impact of Bill 124,[7] which limits base salary increases to one per cent per year for a period of three years.[8]

As collective agreements subject to Bill 124 expire, the FAO forecast assumes that wage growth will revert to the historical average of 2.4 per cent.

The FAO’s spending forecast for hospitals also reflects growth in hospital capacity, which is measured through the number of hospital beds. The FAO uses growth in hospital beds as a proxy for growth in the number of services provided by Ontario hospitals, which determines the required operating funding and staffing. Based on the FAO’s analysis of the Province’s hospital capacity expansion and infrastructure plans from the 2022 Ontario Budget, the FAO estimates that the number of hospital beds in Ontario will increase by 1,400 beds (4.0 per cent) from 2021-22 to 2027-28,[9] which will require approximately 10,000 additional hospital workers (includes nurses and personal support workers (see Chapter 5 for analysis) plus other hospital workers).

given recent elevated inflation, there is the potential for above-average wage settlements,[10] which would lead to higher than projected spending.

The government has appealed this decision. If the government is unsuccessful in its appeal, then the FAO estimates that provincial spending on wages for hospital employees could increase by an additional $3.6 billion over the six-year period to 2027-28.[11]

OHIP provides funding for more than 6,000 insured services to eligible Ontario residents from various providers, including physicians, hospitals, community laboratories, independent health facilities and other clinics.

The largest component of the OHIP program area is physician services, which comprises over 80 per cent of program area spending.

The FAO projects community programs spending will grow at an average annual rate of 5.0 per cent from 2021-22 to 2027-28.

Overall, the FAO estimates that the long-term care program area will have the highest spending growth in the health sector, at an average annual rate of 8.3 per cent from $6.8 billion in 2021-22 to $11.0 billion in 2027-28. This growth is primarily driven by the Province’s commitments to add 30,000 net new long-term care beds by the end of 2028, redevelop approximately 30,000 existing beds, and increase average hours of direct care provided to long-term care residents from a nurse or personal support worker from 2.75 hours in 2018-19 to four hours in 2024-25

The FAO projects other programs spending will decrease at an average annual rate of 1.2 per cent from 2021-22 to 2027-28. This decline in spending is the result of time-limited COVID-19-related spending in 2021-22. Removing the effect of time-limited spending, the FAO estimates other programs spending will grow by an average annual rate of 4.1 per cent from 2019-20 to 2027-28.

Health sector capital assets include approximately 913 buildings, totalling about 90 million square feet, as well as machinery and equipment (such as medical imaging machines and ventilators). The FAO projects 3.1 per cent average annual growth in health capital spending from 2021-22 to 2027-28. This projection is based on the amortization profile of hospital infrastructure assets and the Province’s 10-year infrastructure plan in the 2022 Ontario Budget.

In the 2022 Ontario Budget, the Province plans to invest $44.9 billion in health sector infrastructure over 10 years, including $40.2 billion for hospitals and $4.7 billion for other health sector infrastructure programs. The total 10-year health sector infrastructure investment plan represents an $11.2 billion increase from the 10-year plan in the 2021 Ontario Budget. Most of the 10-year infrastructure spending plan increase is for hospitals ($9.9 billion), with the remaining $1.3 billion increase for other health sector infrastructure programs.

If the $44.9 billion planned investment in health sector infrastructure is achieved, it would be a $13.6 billion (43.3 per cent) increase from the $31.3 billion health sector infrastructure investment over the previous 10 years from 2012-13 to 2021-22. On a real basis, the Province’s 10-year health infrastructure plan in the 2022 budget represents a smaller increase in spending on infrastructure compared to the previous 10-year period. After adjusting for inflation, the Province spent $36.7 billion over the previous 10 years (in 2021 dollars) and plans to spend $40.7 billion (in 2021 dollars) over the next 10 years. Therefore, in real terms, the 10-year health sector infrastructure spending plan in the 2022 budget represents a $4.0 billion (10.8 per cent) increase in investments compared to the previous 10-year period.

In 2005, the Province had approximately 31,865 hospital beds. Over the next 14 years, the Province added 830 hospital beds, an increase of 2.6 per cent, while Ontario’s population increased by 16.1 per cent and the population of Ontarians aged 65 and older, who occupy over 50 per cent of hospital bed days, grew by 56 per cent.

In addition, a growing proportion of existing hospital bed capacity is being occupied by patients waiting to go elsewhere. Limited growth in health sector capacity outside of hospitals, especially in long-term care homes, is contributing to alternate level of care (ALC) patients occupying more hospital beds. A patient is designated as ALC when they no longer need the level of care they are receiving in hospital but continue to occupy a hospital bed while waiting to go elsewhere such as a long-term care home or rehabilitation facility. Between 2012-13 and 2019-20, the share of hospital capacity occupied by ALC patients increased from 13.3 per cent to 17.0 per cent.

From 2017-18 to 2019-20, the average occupancy rate for Ontario’s hospitals was 96 per cent, while each year an average of 42 hospitals reported average occupancy rates for acute care beds of over 100 per cent. High hospital occupancy rates contribute to “hallway health care” with approximately 1,000 patients receiving care in hallways or other unconventional spaces on any given day from 2017-18 to 2019-20.

More recently, in 2020-21 and 2021-22, Ontario had fewer hospitalizations than in either of 2018-19 or 2019-20, due to the COVID-19 pandemic.[21] This resulted in lower overall occupancy and fewer patients receiving care in hallways or other unconventional spaces. However, in the first quarter of 2022-23, occupancy rose to 93 per cent, which is close to the pre-pandemic average, and nearly 1,300 patients received care in hallways or other unconventional spaces on any given day, which is the highest number since the Province started collecting this data in 2017.

In addition to growing numbers of patients receiving care in hallways or unconventional spaces, capacity pressures are manifesting in other hospital functions. For example, wait times for a hospital bed for patients admitted from the emergency department are currently the longest in over 15 years.[22] Finally, capacity pressures can result in hospitals being unable to respond to surges in demand. For example, in November 2022, the Province reported no available paediatric ICU beds for a 12-day period due to the unusual influenza (flu) and respiratory syncytial virus (RSV) seasons.[23]

Overall, the Province plans to add 3,000 net new hospital beds from 2021-22 to 2031-32 through its 10-year hospital infrastructure plan, of which the FAO estimates that 1,400 new hospital beds will be in operation by 2027-28. In addition, the Province has announced that it will continue to fund the operation of beds in hospitals and alternate health facilities that were added in response to the COVID-19 pandemic. The FAO estimates the continuation of these beds will increase hospital capacity by approximately 3,100 beds. Combined, the FAO estimates that hospital bed capacity will increase by approximately 4,500 beds from pre-pandemic levels to the end of the forecast period, from 32,696 beds in 2019-20 to 37,224 beds in 2027-28. This represents a 13.8 per cent increase in hospital beds over the eight-year period, compared to the 2.6 per cent increase in hospital beds over the 14-year period from 2005 to 2019.

Note: Alternate Health Facility refers to beds in alternate health facilities such as retirement homes that are available to hospitals to meet surges in patient demand.

As of September 2022, approximately 5,000 ALC patients were waiting in Ontario hospitals for care elsewhere. Of those patients, about 2,000 were waiting for a long-term care bed and 540 were waiting for home care.

Bill 7 allows hospital patients designated as ALC to be assessed for eligibility for long-term care, discharged from hospital, and admitted to a long-term care home that was not selected by the patient or their substitute decision maker. While patients cannot be physically transferred without consent, hospitals are required to charge discharged patients a fee of $400 every 24 hours that they remain in the hospital.[26] ALC patients can be sent to any appropriate long-term care home within 70 kilometres of their preferred location in southern Ontario and 150 kilometres in northern Ontario.

The second area of focus, which the FAO assumes is intended to free up 500 beds,[27] is through increased funding for community care so that ALC patients waiting for home care can leave the hospital faster.[28]

First, with respect to the 4,500 beds that the Province plans to add by 2027-28, as outlined in Chapter 3, the FAO estimates that the Province has not allocated sufficient funding to the health sector. To ensure the 4,500 additional hospital beds can be operated, the Province must increase funding to the health sector beginning in 2023-24.

Second, to free up 2,500 existing beds occupied by ALC patients, the Province will need to place all 2,000 ALC patients waiting for a long-term care bed, as of September 2022, and permanently free up those hospital beds for other patients. There are over 39,000 Ontarians on the waitlist for long-term care and, in September of 2022, the median wait time for hospital ALC patients discharged to long-term care was 39 days. To free up all 2,000 beds occupied by ALC patients waiting for a long-term care placement, the Province must effectively reduce time to placement from hospitals from 39 days to 0 days. Bill 7 does give patients in hospitals waiting for a long-term care bed priority over patients waiting in the community,[29] however, a space must still be available for the patient and the long-term care home must have the necessary supports to meet the patient’s care needs. Compounding this issue is that patients that wait the longest in hospitals for long-term care tend to have specialized needs and support requirements that are not offered in all long-term care homes.[30] Overall, as of December 2022, the Province had reduced the number of beds occupied by ALC patients waiting for long-term care by 350.[31] However, this means that the Province must permanently free up an additional 1,650 beds occupied by ALC patients waiting for a long-term care bed to achieve its target. For the reasons stated above, the FAO expects that this will be unlikely.

Finally, even if the Province succeeds in increasing available hospital capacity by 7,000 beds, that will not be sufficient to serve the growth in demand for hospital services from Ontario’s growing and aging population. From 2019-20 to 2027-28, the FAO estimates that Ontario’s population will increase by 12 per cent, while the number of Ontarians aged 65 and over will increase by 30 per cent. In total, the FAO estimates that this population growth and aging will increase demand for hospital services by 21 per cent.[32] As a result, the Province would need to increase available hospital capacity by 7,500 beds just to meet the projected growth in demand for hospital services from 2019-20 to 2027-28.

Therefore, even if the Province achieves its plan to add 4,500 new hospital beds and free up 2,500 existing beds, it will still be 500 beds short of the estimated 7,500 beds needed just to serve the growth in demand for hospital services from 2019-20 to 2027-28. This suggests that without additional measures, Ontario will have less available hospital capacity relative to need in 2027-28 than in 2019-20.

On average, older Ontarians use more health resources than younger Ontarians. Although the average Ontarian benefits from $4,900 of health care spending per year, Ontarians aged 65 to 69 benefit from $7,500 of health care spending per year on average, while Ontarians aged between 75 and 79 benefit from $11,900, and Ontarians over the age of 90 benefit from $29,600.

In 2021-22, the per diem cost of home care in Ontario was $36, which was significantly less than long-term care at $151 or a hospital bed at $722.

From 2012-13 to 2019-20, the number of nursing and personal support services provided by home care programs grew by 34 per cent, which is higher than the 27 per cent growth in Ontario seniors (aged 65 and over), who receive the majority of home care services.

n 2021, 6.3 per cent of Ontarians received formal home care services, which is higher than the Canadian average of 6.1 per cent

Also, in 2020-21, the median wait time for home care in Ontario was two days, which was either below or tied with all other reporting provinces and territories.[34]

However, over the same time period, the Province did not make a similar investment in long-term care to match the expansion of home care. In 2011-12, the Province had 78,053 long-term care beds. Over the next eight years, the Province added 87 long-term care beds, an increase of 0.1 per cent, while the population of Ontarians aged 75 and older, who occupy over 80 per cent of long-term care beds, grew by 24 per cent.

This limited growth in the number of long-term care beds has led to long wait times and waitlists for long-term care. As of November 2022, over 39,000 Ontarians were on the waitlist for a long-term care placement and the median wait time for a long-term care bed was 126 days

Looking ahead, the number of Ontario seniors (aged 65 and over) is projected to increase by 22 per cent from 2021-22 to 2027-28. This will significantly increase demand for home care and long-term care services. The Province’s plan to preserve hospital capacity and ensure Ontario seniors can access care in the appropriate setting involves significant investments to expand the capacity of both home care and long-term care.

The FAO estimates that the new funding will result in home care spending growth averaging 6.7 per cent per year, from $2.9 billion in 2019-20 to $4.0 in 2024-25

This spending growth will increase the number of nursing and personal support hours by 18 per cent from 2019-20 to 2024-25.

Overall, the FAO estimates that the Province’s home care expansion will increase the number of Ontarians aged 65 and over who receive home care services from 410,000 in 2019-20 to 485,000 in 2024-25.

However, over the same time period, the FAO estimates that the number of Ontarians aged 65 and over will also increase by 18 per cent. This means that by 2024-25, the number of funded hours for nursing and personal support services per Ontarian aged 65 and over will be 17.5, the same level as in 2019-20.

The FAO estimates that these two commitments will result in average annual long-term care program spending growth of 12.2 per cent from 2019-20 to 2027-28. This growth is significantly higher than the average annual growth of 2.4 per cent from 2011-12 to 2019-20.

In 2019-20, Ontario had approximately 78,200 long-term care beds. The FAO estimates that the number of beds will increase to approximately 105,000 by the end of 2027-28.[37] From 2019-20 to 2027-28, the number of long-term care beds will increase by 34 per cent. This growth in long-term care capacity is significantly higher than the 0.1 per cent growth from 2011-12 to 2019-20.

However, between 2019-20 and 2027-28, the FAO estimates that the number of Ontarians aged 75 and over will increase by 37 per cent compared to the projected 34 per cent increase in the number of beds. Therefore, despite the significant increase in the number of long-term care beds by 2027-28, the FAO estimates that Ontario will still have fewer beds per Ontarian aged 75 over in 2027-28 than it did in 2019-20.

For home care, the number of nursing and personal care hours per Ontarian aged 65 and over will be about the same in 2024-25 as it was in 2019-20. For long-term care, the number of beds per 1,000 Ontarians aged 75 and over will decline slightly from 71 in 2019-20 to 70 in 2027-28.

In response to the COVID-19 pandemic, the Province issued directives to pause elective surgical procedures[39] three times to preserve hospital capacity. These directives were issued on March 15, 2020, April 9, 2021 and January 5, 2022, with each lasting between five and 10 weeks.

Largely as a result of the directives to pause elective surgical procedures, and also due to the impact of the COVID-19 pandemic on hospital operations, 398,000 fewer surgeries were performed in the 2020 to 2022 period than would have occurred if 2019 surgical volumes had been maintained. This represents an average 20 per cent reduction in surgery volumes each year, with reductions of 187,500 (29 per cent) in 2020, 117,100 (18 per cent) in 2021 and 93,800 (14 per cent) in 2022.[40]

Although 398,000 fewer surgeries were performed over three years, from 2020 to 2022, the surgery waitlist only increased by 50,000. As of September 2022, approximately 250,000 patients were on waitlists for surgical procedures, which is 50,000 more patients than the pre-pandemic level of 200,000.

As of September 2022, of the total surgery waitlist of 250,000, approximately 107,000 (43 per cent) were long-waiters, up from an average of 38,000 (20 per cent) long-waiters on the surgery waitlist before the COVID-19 pandemic.

With a 50,000 patient increase in the surgery waitlist and fewer surgeries being performed, the implied average wait time for surgeries has increased. In 2019, the average wait time for surgery was 3.7 months. In 2022, the average wait time was 5.5 months, a 48 per cent increase from 2019.[41]

To help achieve these targets, the Province has provided premium pricing incentives to hospitals to increase surgical volumes. The Province has also provided funding to increase the number of procedures performed at paediatric and private hospitals, and independent health facilities. In total, the Province has allocated $858 million for surgical recovery from 2020-21 to 2022-23, $326 million of which is allocated in 2022-23.

Of this $858 million, approximately $603 million has been allocated to increase surgical volumes and increase the number of surgeries done after hours at hospitals, as well as for additional operating hours for MRI and CT machines. An additional $37 million has been allocated to paediatric and private hospitals, and to independent health facilities for OHIP-covered surgeries and MRI/CT hours. The remaining $218 million has been allocated to a variety of measures that include training, supplies and equipment.

Despite the Province’s $858 million investment over three years, the number of surgeries performed has not returned to pre-pandemic levels. Looking only at months not affected by elective surgery pauses, the average number of surgeries performed in each month from 2020 to 2022 was significantly lower than in 2019, with average monthly surgeries performed 14 per cent lower in 2020, 12 per cent lower in 2021 and eight per cent lower in 2022 (as of September 2022).

Monthly surgical volumes in 2022 remained below 2019 levels due to the on-going impact of COVID-19 and the impact on hospital operations from the unusual influenza (flu) and respiratory syncytial virus (RSV) seasons.[42] Staffing shortages have also caused hospitals to ramp down the number of surgical procedures (see section E).[43]

The reason the surgery waitlist has increased by only 50,000, when 398,000 fewer procedures were performed from 2020 to 2022 as compared to 2019 levels, is that fewer Ontarians were added to the surgical waitlist compared to pre-pandemic levels. For example, from March 2022[44] to September 2022, an average of 51,500 Ontarians were added to the surgical waitlist each month. This is 13 per cent lower than the average of 59,100 patients added to the surgery waitlist each month from March to September of 2019. This 13 per cent decline in monthly waitlist additions from March to September of 2022 is greater than the eight per cent decline in monthly surgeries performed over the same period.[45]

The growth in the waitlist occurred mostly during the second and third directives to pause elective procedures where the reduction in diagnostic imaging and primary care was not as significant. Outside the periods when elective surgeries were paused, the number of surgeries performed has outpaced waitlist additions and the Province has been able to gradually reduce the waitlist. For example, following the end of the last directive to pause surgeries in March 2022, the waitlist has been gradually reduced from 263,000 in March of 2022 to approximately 250,000 in September of 2022.

As of September 2022, the most recent complete data available to the FAO, the surgery waitlist was 250,000 patients.[46] The Province’s target is to reduce the waitlist to 200,000 by March 2023. To achieve this target, the rate of decline in the waitlist would need to be significantly faster than what the Province has achieved up to September 2022.

After pauses of elective surgeries in 2021 and 2022, the waitlist has been reduced by an average of 2,280 patients per month. Assuming no further interruptions, similar volumes of surgeries being performed and similar volumes of patients being added to the waitlist, the Province would reduce the surgical waitlist back to 200,000 patients by July 2024. This would be 16 months later than the Province’s target of March 2023.

As of September 2022, the number of patients on the surgery waitlist classified as long-waiters was 107,000, which was the highest number recorded since the start of the pandemic. Consequently, without additional measures, the Province will not achieve its goal of reducing the number of patients on the surgery waitlist classified as long-waiters to the pre-pandemic level of 38,000.

In 2021-22, Ontario emergency departments saw an average of 445,000 visits per month which is only nine per cent below typical volumes. From April to November in 2022-23, there was an average of 482,000 emergency department visits per month, which is about one per cent below typical volumes.[48

In 2022-23, the average length of stay in an emergency department for all patients was approximately 6.1 hours.[50] This is 30 per cent higher than wait times over the five-year period prior to the COVID-19 pandemic and is also the longest average wait time recorded in over 15 years.

The FAO estimates 143 of the 145 emergency department closures have occurred in small population centres with populations of less than 30,000.[55] For perspective, about 40 per cent of emergency departments in Ontario are in small population centres and those emergency departments represent 99 per cent of all emergency department closures.

From 2017-18 to 2019-20, emergency department wait times were significantly lower despite higher patient volumes and wait times for Ontario emergency departments were below the Canadian average in each year.[57] Even looking at hospitals with the longest wait times in 2022, for the most part, those hospitals have lower patient volumes than before the COVID-19 pandemic. Of the 20 hospitals with the longest emergency department wait times for admitted patients in 2022-23, 17 have lower patient volumes than the 2017 to 2019 average. This suggests that the more pressing immediate problem is emergency department staffing as opposed to patient volumes/demand. However, the Province’s emergency department staffing measures only provide hospitals with flexibility to deal with short-term issues. The measures do not provide a sustained increase in emergency department staff.

Since the start of the COVID-19 pandemic, health sector job vacancies have more than doubled in Ontario from 14,800 in the fourth quarter of 2019 to 34,800 in the third quarter of 2022. These vacancies are a result of the number of positions in the health sector growing faster than the number of workers.

In the third quarter of 2022, there were 14,575 vacant nursing positions representing a vacancy rate of eight per cent, while there were 12,300 vacant personal support worker (PSW) positions representing eight percent of all PSW positions. To return to pre-pandemic vacancy rates,[58] the FAO estimates that 9,700 nurses and 7,700 PSWs are needed.

Furthermore, the FAO estimates that about 23,800 additional nurses and 44,100 additional personal support workers will be needed in hospitals, long-term care and home care by 2027-28 to meet government program expansion commitments. These commitments include adding approximately 1,000 new hospital beds from 2022-23 to 2027-28 (see section A for details), expanding home care (see section B for details), and creating 30,000 new long-term care beds and increasing direct care hours for residents in long-term care homes (see section B for details).

While wage data is not available specifically for personal support workers, in 2022, weekly average earnings in Ontario long-term care facilities were 1.3 per cent below the national average, despite the Province’s $3 per hour wage increase for PSWs in long-term care, first introduced in October 2020 (see chapter 4), and Ontario’s higher cost of living.[62]

Based on the FAO’s analysis, the Province’s key measures to increase nursing employment are accelerating the registration of internationally educated nurses and increasing nursing student enrolment. The registration of internationally educated nurses (IENs) is being achieved primarily by relaxing regulatory barriers to registration, including Ontario work experience requirements and language testing requirements. The registration of IENs is also being supported by the establishment of the temporary registrant class, timeliness for processing of applications, expansions of the Supervised Practice Experience Partnership (SPEP) Program, and temporary coverage of professional fees. Lastly, the Province temporarily increased nursing enrolment by 2,000 spaces in 2021-22 and has committed to permanently increase nursing enrolment by 1,500 seats in 2023, consisting of spaces for 500 registered practical nurses and 1,000 registered nurses.

The Province’s key measures to increase personal support worker employment are grants to students and wage increases. In 2021-22, the Province committed to spend up to $200 million to train up to 16,200 personal support workers through publicly assisted colleges, private career colleges and school boards. From this overall funding, the Province committed $115 million to train up to 6,000 PSWs over six months at public colleges starting in April 2021[64] and $86 million to train up to 8,000 new PSWs at private career colleges and school boards in 2021-22.[65] Subsequently, the Province announced $54.7 million to train up to 4,000 new PSWs at private career colleges in summer 2022.[66] Regarding wage increases, in October 2020, in response to the COVID-19 pandemic, the Province temporarily increased wages for personal support workers by $3 per hour in home care and long-term care and $2 per hour in hospitals. In 2022, these wage increases were made permanent (see chapter 4).

The FAO estimates that 34,800 more nurses will be required by 2027 but only 31,900 will be added, resulting in a shortfall of 2,900 nurses. Over the next three years, the shortage will average approximately 10,000 nurses, and then gradually decline as growth in demand for nurses from long-term care and hospitals slows, and the incremental graduates from increased enrolment start to enter the labour market.

Based on the FAO’s analysis, the shortage of nurses will continue across the forecast period.

Measures to accelerate the registration of internationally trained nurses have had success to date. In 2022, Ontario registered 5,125 new internationally educated nurses, up from an average of 1,411 per year from 2015 to 2019. However, some of this success was due to a backlog in active applications, which reached 14,880 in 2020. Without new measures to increase the immigration of nurses to Ontario, the FAO assesses that maintaining the 2022 increase in registrations will be challenging. Given this, the FAO assumes that Ontario will add 3,600 incremental internationally educated nurses until 2024 then, starting in 2025, the FAO assumes that Ontario will continue to register a more sustainable 2,000 incremental internationally educated nurses each year.

As noted above, the Province provided funding for a temporary 2,000 student increase in nursing enrolment in 2021-22, consisting of spaces for 1,453 registered practical nurses and 551 registered nurses. The Province has also committed to permanently increase nursing enrolment by 1,500 seats in 2023, consisting of 500 spaces for registered practical nurses and 1,000 spaces for registered nurses.[67] Increased enrolment is forecasted to add 4,100 nurses over our projection period.[68]

In addition to policy measures, nursing employment will experience natural growth. Natural growth reflects the ongoing net effect of factors that add to the supply of nurses (e.g., graduations and immigration) and factors that detract from the supply of nurses (e.g., emigration, exits to other careers and retirements). The FAO estimates that natural growth will add a net 2,400 nurses each year for hospitals, home care and long-term care, consistent with pre-pandemic trends.

In short, as of the writing of this report, the FAO projects that the health workforce policy measures announced by the Province, along with natural growth, will add 53,700 nurses and PSWs over the six-year period to 2027-28. Nevertheless, this increase in nurses and PSWs will not be sufficient to address current staffing shortages and meet Ontario’s commitments to expand care in hospitals, long-term care and home care, with an expected shortfall of 33,000 nurses and PSWs in 2027-28.

Based on a recent survey of 100 not-for-profit LTC homes, 44 per cent report that they are unsure whether they will meet the government’s target of four hours of daily direct care by 2024-25 due to staffing shortages and higher fees charged by temporary staffing agencies.[71]

Academic literature predicts that health care staffing shortages result in adverse outcomes for patients, including more infections, more pressure injuries, more patient falls and higher mortality.[72] For nurses, understaffing contributes to increased stress, increased dissatisfaction and ultimately increased turnover.[73]

However, the FAO also projects that without additional measures, there will be a shortfall of 33,000 nurses and PSWs in 2027-28. In order to address this shortfall, the Province may have to introduce new measures that would increase spending above the FAO’s health sector spending outlook. For example, such measures could include increasing wages, reducing workloads, structuring staffing to use more desirable full-time positions, increasing reliance on agency workers and private providers not subject to wage restraints, and/or adding new funding for education or training.

The FAO’s analysis assumes that natural growth in the number of nurses and PSWs in hospitals, home and community care, and long-term care will follow historical trends, but certain factors could lead to a lower than historical increase. There are some indications that hospitals are facing challenges retaining nurses due to low job satisfaction from burnout and low wage growth. Consistent with this, the Ontario Hospitals Association reported 14.5 per cent turnover in 2021-22 compared with 8.4 per cent in 2019-20.[74] As noted above, in 2022, wages for Ontario nurses were the lowest in Canada, while wages for workers in Ontario long-term care facilities were below the Canadian average.

For clarity, totals reflect the number of workers required to restore and maintain normal staffing levels in the hospitals, home and community care, and long-term care program areas, while meeting the government’s program expansion commitments in these areas. The FAO’s projection for the number of nurses and personal support workers required to be hired does not reflect an assessment about the quality of services that should be provided by these program

As of the 2020–21 Third Quarter Finances, the government is projecting a deficit of $38.5 billion in 2020–21, unchanged from the outlook presented in the 2020 Budget.

Revenues in 2020–21 are projected to be $151.7 billion, $0.6 billion higher than forecast in the 2020 Budget. The higher revenue forecast largely reflects stronger taxation revenues, attributable to a smaller economic decline in 2020 than the prudent planning assumptions in the 2020 Budget. The forecasts for Government of Canada transfers and net income from Government Business Enterprises are also higher, while other non-tax revenue is lower.

Program expenses are projected to be $2.6 billion higher than forecast in the 2020 Budget, largely due to investments in hospitals, long-term care homes, and business support, primarily offset from existing contingencies.

Since the 2020 Budget, the government has fully allocated all of the time-limited pandemic response funding and extraordinary contingencies of $13.3 billion in 2020–21. In light of this, and to help mitigate expense risks for the remainder of 2020–21, the standard Contingency Fund has been allocated an additional $2.1 billion for 2020–21, given the uncertain and unprecedented impact of the global pandemic.

The 2020 Budget included a $2.5 billion reserve in 2020–21 to protect the fiscal outlook against any unforeseen adverse changes in the Province’s revenue and expense forecasts. With the release of the 2020–21 Third Quarter Finances, the reserve has been reduced to $0.5 billion, which could be used to address any unforeseen events that could arise before year-end.

The forecast for Total Taxation Revenue has increased by $1.5 billion compared to the 2020 Budget. Key changes in the taxation revenue outlook compared to the 2020 Budget include:

Corporations Tax revenue increased by $1.5 billion (15.0 per cent), mainly due to higher amounts from processing 2019 tax returns;

155

Personal Income Tax revenue decreased by $1.0 billion (2.8 per cent), mainly due to lower amounts from processing tax assessments for 2019 and prior years; and

869

Program Expense Changes Since the 2020 Budget — Supports to Protect (Additional Allocations Since 2020 Budget) — Additional Funding for Hospitals

609

Program Expense Changes Since the 2020 Budget — Supports to Protect (Additional Allocations Since 2020 Budget) — More Purchases of Personal Protective Equipment (PPE)

Program Expense Changes Since the 2020 Budget — Supports to Protect (Additional Allocations Since 2020 Budget) — Continued Long-Term Care Sector Response to COVID‑19

398

Program Expense Changes Since the 2020 Budget — Supports to Protect (Additional Allocations Since 2020 Budget) — Medical and Laboratory Equipment

Sales Tax revenue increased by $1.1 billion (4.5 per cent), mainly reflecting the strong rebound in household consumption spending during the second half of 2020;

148

Program Expense Changes Since the 2020 Budget — Supports to Protect (Additional Allocations Since 2020 Budget) — OHIP Funding and Assessment Centres

135

Program Expense Changes Since the 2020 Budget — Supports to Protect (Additional Allocations Since 2020 Budget) — Vaccine Administration

125

Program Expense Changes Since the 2020 Budget — Supports to Protect (Additional Allocations Since 2020 Budget) — Additional Critical Care Beds

Program Expense Changes Since the 2020 Budget — Supports to Protect (Additional Allocations Since 2020 Budget) — COVID‑19 Testing Centres

118

$609 million to support the procurement of additional personal protective equipment and critical supplies and equipment and continued support for essential supply chain operations in the health care sector;

45

1,400

Program Expense Changes Since the 2020 Budget — Support for People, Jobs and Recovery (Additional Allocations Since 2020 Budget) — Ontario Small Business Support Grant

Program Expense Changes Since the 2020 Budget — Support for People, Jobs and Recovery (Additional Allocations Since 2020 Budget) — Additional Support for Businesses — Property Taxes and Energy Bills

300

$869 million in additional investments for the hospital sector for supplies and equipment related to addressing the surge in COVID‑19 cases, including testing, swabs, saliva tubes and test kits, bringing the total increase in funding to hospitals since 2019–20 to $3.4 billion;

Program Expense Changes Since the 2020 Budget — Supports to Protect (Additional Allocations Since 2020 Budget) — Telemedicine/Virtual Care Utilization 78 Program Expense Changes Since the 2020 Budget — Supports to Protect (Additional Allocations Since 2020 Budget) — Additional COVID‑19 Mental Health and Addictions Supports

$398 million to respond to the impact of COVID‑19 in the long-term care sector, including through continued prevention and containment measures, funding to support implementation of testing guidelines, and support for operators who have been impacted by the changes in occupancy numbers due to COVID‑19;   $155 million to support managing the COVID‑19 pandemic with investments in critical medical and laboratory equipment; $148 million to provide health care support for uninsured patients and operate COVID‑19 Assessment Centres; $135 million for administration of the Province’s COVID‑19 vaccination program. The government’s vaccine rollout is underway since launching in December. Based on available supply as of February 4, more than 350,000 doses have been administered with more than 80,000 people fully vaccinated; $125 million in COVID‑19 investments in the hospital sector through the planned addition of more than 500 critical care beds to address urgent operating pressures and build capacity in the health care system to respond to a resurgence in cases of COVID‑19; $118 million in testing, laboratory services as well as purchasing and distribution of medical equipment; $78 million investment to support an increase in demand for Telemedicine services during COVID‑19. Through this investment, providers will be able to leverage a variety of virtual care technologies that best meet the needs of their patients while helping to reduce the spread of COVID‑19; $45 million investment to support a comprehensive cross-ministry plan to address mental health and addictions supports related to COVID‑19, which has exacerbated mental health issues due to self-isolation and job losses. The investments will support building healthier and safer communities, including increasing service provision, providing tools and resources, developing and implementing training, and providing housing supports;

$1.4 billion to launch the Ontario Small Business Support Grant to support small businesses that are required to close or significantly restrict services under the provincewide shutdown effective December 26, 2020, with one-time grants of up to $20,000;

$300 million in additional support made available, for a total of $600 million, for property tax and energy bill relief to eligible businesses that were required to close or significantly restrict services due to enhanced public health measures;

Between February and May, Ontario employment declined by 1,134,700 (−15.1 per cent). Since June, employment rebounded by 729,100 net jobs and as of January was 405,600 (−5.4 per cent) below the February 2020 level. As of January 2021, the unemployment rate was 10.2 per cent, down from a high of 13.5 per cent in May.

Private-sector forecasters, on average, project real GDP to rise by 4.5 per cent in 2021, easing from an average of 5.0 per cent in October 2020 and slower than the 4.9 per cent increase projected in the 2020 Budget.

About 1.4 million Canadian adults indicated they had symptoms at least three months after a positive COVID-19 test or suspected infection

The provisional results of the CCAHS are showing that among Canadian adults who indicated a positive test or suspected infection before December 2021, 25.8% had symptoms at least three months after their infection. For those indicating an infection experienced in December 2021 or after, the percentage that had symptoms at least three months after infection decreased to 10.5%.

Canadians with symptoms at least three months after an initial or suspected infection indicated that fatigue (72.1%) was the most reported unresolved symptom, followed by cough (39.3%), shortness of breath (38.5%) and brain fog (32.9%).

Among Canadian adults who rated their symptoms as severe at the time of their first positive test or suspected infection, 36.4% indicated having symptoms at least three months after their infection. As indicated by Chart 1, the percentage who indicated longer-term symptoms decreased as the severity of their initial symptoms decreased. Among those who rated the symptoms as moderate, 15.0% reported longer-term symptoms, while 6.3% who reported a mild case of COVID-19 reported longer-term symptoms.

Of those who indicated a previous positive test or a suspected infection for COVID-19, 14.8% experienced symptoms at least three months after their infection. This translates into about 1.4 million Canadian adults or 4.6% of the Canadian population aged 18 years and older. A higher percentage of women (18.0%) reported prolonged symptoms compared with men (11.6%). No significant differences by age group were found in the percentage of Canadian adults reporting prolonged symptoms

Of Canadian adults who reported symptoms at least three months after being infected, 32.5% had recovered from their initial symptoms before symptoms returned. A higher percentage of men (37.2%) than women (28.7%) indicated their symptoms had resolved and then returned.

The U.S. Centers for Disease Control and Prevention (CDC) updated its guidelines in early October to include that COVID-19 can sometimes be spread by airborne transmission, after mistakenly posting and later removing a draft version of guidelines in late September.

The WHO amended its guidelines days after the letter and acknowledged the possibility that aerosols can lead to outbreaks of COVID-19 in places like choir practices, restaurants and fitness classes.

"I do think that because it's winter, because we're all going inside, we're learning more about droplets and aerosols." 

Marr said that updated PHAC guidance on three-layer non-medical masks was in line with the threat of aerosol transmission. 

"If we were only concerned about large droplets, then pretty much almost any piece of single layer of fabric would work," she said.

"But because we are concerned about aerosols, then we do need to think about the quality and fit of our masks and we know that having multiple layers improves the filtering performance of masks." 

PHAC previously told CBC News in a statement on Sept. 24 that it was not updating its guidance on airborne transmission — even though it said there "have been situations where aerosol transmission in closed settings has occurred."

The agency said at the time its guidance would remain the same: limit time spent in closed spaces, crowded places and close contact situations, while maintaining physical distancing, hand-washing and mask-wearing.

Infectious diseases specialist and medical microbiologist Dr. Raymond Tellier, who is also an associate medical professor at McGill University in Montreal, welcomed the updated federal guidelines but said they also have implications on the personal protective equipment (PPE) of front-line health-care workers. 

"Since we now recognize that aerosolized particles play a role, especially at short distances where they are in greater concentration, people that have to work at close range of infected people to provide care must take this into account as well as part of PPE," he said. 

"So that is something that I would assume is still in the works, but it's an important point that we must not forget." 

"Distancing helps, masks help, ventilation helps — no one of these things is perfect," Marr said. 

Aerosol transmission, she said, would not be addressed by focusing on just one of these measures alone. "But when we combine all these things, we haven't seen any outbreaks."

PHAC also said in September that it was reviewing evidence on the topic and acknowledged that aerosols could be suspended in the air and infect others nearby, but it wasn't known at what rate that happens and under what conditions.

Studies of superspreading events, such as a choir practice in Washington state, a call centre in South Korea and a restaurant in China, have supported the conclusion that some degree of transmission is occurring through aerosols.

Virus particles were also found in the air at a nursing home outbreak in May in Montreal, where a faulty ventilation system may have been a source of transmission that infected 226 residents and 148 employees.

"The gym followed all the guidelines: they had distancing, they did hygiene, they had people wearing masks before and after," Marr said, "but if it were just all large droplets, then the distancing and hygiene would be sufficient — but obviously, it wasn't."

"Because aerosols do play an important role in transmission and if you just distance and just do hygiene, that's not enough."

Source equipment needed to support Canada’s response to COVID-19 here in Canada. The Government of Canada will use existing supply arrangements and innovative, flexible procurement approaches. It is also reaching out to suppliers to identify and purchase equipment, supplies, and services needed for Canada’s response to COVID-19. With a view to longer-term support, the Government of Canada will ensure procurement flexibility to support innovation and build domestic manufacturing capacity to supply critical health supplies to Canadians.

On March 11, 2020, the Government of Canada announced a more than $1 billion package to help minimize the health, economic, and social impacts of the COVID-19 outbreak, which includes $50 million to help ensure adequate supplies of personal protective equipment for provinces and territories, as well as to address federal needs.

Between 2013 and 2018, registered nurse employment levels across all sectors remained the same, while registered practical nurse levels rose by 15.1% and nurse practitioner levels rose by 130.6%. The number of registered nursing staff of all nursing classes rose by 9.5%. footnote 21 [21]

58% of employees are personal support workers (PSW), followed by registered nurses (RNs) at 25% approximately 40% of registered nurses and registered practical nurses (RPNs), and 63% of nurse practitioners work full-time approximately 25% of personal support workers who have two or more years of experience leave the sector annually

While the demand for long-term care and resident acuity have increased year over year, staffing levels and access to training have not kept a corresponding pace. Over time, the demand placed on long-term care staff often causes greater workload. This can increase the risk of worker injury, lead to less attention and time spent per resident and contribute to a stressful working environment. Issues such as working conditions and a negative public image have also contributed to staffing shortages in the sector.

While the province's legislative and regulatory framework is designed to ensure that long-term care residents live in a safe environment and hold long-term care homes accountable, several operators and associations have reported that the framework can be a barrier for exploring potential solutions for staffing shortages and issues.

Across the sector, long-term care partners have identified the current culture of long-term care as one based heavily on compliance, which can create a punitive environment for staff. It was also heard that the current funding model for long-term care homes is too complex and requires high levels of documentation, which takes staff away from spending quality time with residents.

Action must to be taken to: urgently address the staffing crisis in long-term care make long-term care homes a better place to live and work implement staffing approaches that reflect and respond to the complexity of the sector and diverse resident needs

The Advisory Group provides recommendations within five priority areas to improve staffing across the sector: The number of staff working in long-term care needs to increase and more funding will be required to achieve that goal. Staffing investment Minimum daily average of four hours of direct care per resident Guidelines for improving staffing ratios and skill mix for PSWs, nursing staff, and allied health professionals, with variance to address specific circumstances. The culture of long-term care needs to change – at both the system and individual home level Regulatory modernization A quality improvement approach to sector oversight Renewed performance measurements A strong coherent philosophy of care Recognition of the critical role of PSWs Respectful team environment Workload and working conditions must get better, to retain staff and improve the conditions for care. Compensation Full-time and part-time employment Protection from physical, mental and emotional risk Charting and documentation Medication management Excellence in long-term care requires effective leadership and access to specialized expertise Clarifying the role and accountability of the Medical Director Expanding the use of Nurse Practitioners Ensuring access to strong Infection Prevention and Control (IPAC) expertise Accessing specialists Attract and prepare the right people for employment in long-term care, and provide opportunities for learning and growth. Attracting people with the right personal attributes through: improved public perception stronger relationships with secondary schools enhanced supports for new graduates expanding the labour pool Aligning the number of graduates with needs across the health care sector Addressing educational requirements for the long-term care sector by: increasing onsite experiences for students promoting preceptorships Supporting staff to stay current, gain new skills and develop specialized expertise, including: continuing education micro-credentialing and job laddering

A high concentration of outbreaks (defined as a single, laboratory confirmed case of COVID-19 in a resident or staff member footnote 2 [2] ) and mortality occurred within Ontario's long-term care homes. footnote 3 [3]

To address this recommendation, the Ministry of Long-Term Care launched a long-term care staffing study in early 2020, with support from an external Advisory Group. This group was instructed to directly respond to Recommendation 85, as well as to seek broader input on a wider range of long-term care staffing issues.

As of mid-July 2020, 21.5% of confirmed cases of COVID-19 in Ontario were reported to be long-term care residents and staff, and 63.7% of deaths with COVID-19 were long-term care residents and staff. footnote 4 [4]

Long-term care homes employ over 100,000 staff across the province, not including staff service providers who come into the home to provide special services such as x-ray technicians and optometrists. footnote 5 [5] As of 2018, homes reported over 56,000 full time equivalent (FTE) positions that provide direct care to residents across the sector, compared to 43,023 reported FTEs in 2009. footnote 6 [6] The number of beds increased by 2,799 in the same time, which is approximately a four percent increase in beds.

The largest proportion of employees in long-term care are: personal support workers (58%) registered nursing staff (including registered practical nurses, registered nurses, and nurse practitioners) (25%) allied health professionals and programming support (such as activity assistants, dietitians, occupational and physical therapists, and social workers) (12%)

Each year, long-term care homes across Ontario submit reports about staffing to the ministry. This information is used to generate the Long-Term Care Home Staffing Report (Staffing Report). footnote 7 [7] According to the latest available report (2018), 41% of PSWs work full-time, 48% work part-time, and 10.7% are casual. footnote 8 [8] , footnote 9 [9] Approximately half of these employees would prefer to work more hours, and 7% would prefer to work less; while 43% are satisfied with the number of hours they work. footnote 10 [10]

Personal support workers (PSWs) in the health care sector As of 2018, there were 100,000 PSWs employed in Ontario in all healthcare sectors. footnote 11 [11] 50,000 of these employees work in long-term care, where they share the equivalent of 32,700 FTEs. 90% of the personal support worker workforce in the health care sector is female. 50% of the personal support worker workforce in the health care sector are between 35 and 54 years old 25% of the remaining personal support workers are 55 years or older. 41% of the personal support worker workforce in the health care sector are visible minorities

MLTC understands that the number of training positions has not declined, but instead there has been a reduced interest of students to enter the PSW training programs. footnote 12 [12] 2015/2016 - Over 8,000 students enrolled in personal support worker training programs (for example, public programs, private programs and boards of education). 2018/2019 - Approximately 6,500 students enrolled in personal support worker training programs. PSW Retention Within The Health Care Sector Approximately 25% of personal support workers who have two or more years of experience leave the long-term care sector annually According to Health Force Ontario, 50% of personal support workers are retained in the health care sector for fewer than 5 years, and 43% left the sector due to burnout of working short staffed. footnote 13 [13] Approximately 40% of personal support workers have left the health care sector after graduating or within a year of training The average overall job tenure of a personal support worker (in all sectors) has dropped 10 months to 85-90 months between 2015 and 2017. Turnover is highest for part-time and casual positions predominantly held by entry-level personal support workers.

Registered nursing staff are the second largest population of long-term care employees: 63% of nurse practitioners (NPs), 40% of registered nurses (RNs), and 39% of registered practical nurses (RPNs) work full time 35% of nurse practitioners, 41% of registered nurses, and 45% of registered practical nurses work part time 2% of nurse practitioners, 19% of registered nurses, and 16% of registered practical nurses work 'casual' footnote 18 [18]

Approximately 30% of registered nurses and registered practical nurses working in long-term care hold two or more jobs. footnote 19 [19]

Registered nursing staff in the long-term care sector In 2018, 23,701 registered practical nurses, registered nurses and nurse practitioners were employed in the long-term care sector. footnote 20 [20] 62.9% registered practical nurses 36.5% registered nurses 0.6% nurse practioners

Long-term care homes employ over 100,000 people across Ontario They serve an increasingly medically complex population of approximately 78,000 residents.

New graduates of PSW programs find the biggest gap is in preparedness for the speed at which tasks need to be completed. Task shifting, 'working short', and other pressures can make it difficult to utilize the concepts and techniques learned in the classroom. footnote 68

Allied health professionals and programming support In 2018, 9,700 allied health professionals and programming support staff worked in the long-term care sector. footnote 25 [25] This group of staff includes, but is not limited to: Dieticians Health Care Aides Physiotherapists Administrative Staff Social Workers

The mix of these groups can differ slightly depending on the type of home. For the top 10 job classifications, homes have largely the same staffing mix. However, slight variations exist; for example, homes of under 64 beds tend to have fewer PSWs and more RNs and healthcare aides per resident, than larger homes.

he provincial government provides 60% to 70% of home funding, and the remainder comes from sources such as resident co-payments, fundraising, and municipal governments. footnote 27 [27] How homes can spend this funding is prescribed by eligibility criteria, yet it can still vary to a degree.

For instance, total spending on compensation accounts for approximately 71.3% of total expenses in for-profit homes, 73.3% in not-for profit homes, and 81% in homes operated by municipalities. footnote 28 [28] This variation may be due to different funding sources such as municipal government funding and fundraising, and how these funds are allocated within each home.

As of 2018, homes report an average of 3.73 direct hours of care per resident, per day based on paid hours. This breaks down to an average of two hours and 18 minutes from PSWs, one hour and 2 minutes from RNs or RPNs, and 24 minutes from allied health professionals and programming support. The chart below depicts how paid care hours for caregiving staff per resident has increased by 15% between 2009 and 2018. footnote 30 [30]

Worked hours are the hours that are spent by staff carrying out the mandate of theservice, for example, staff are present and available for work. Worked hours include regular worked hours, worked statutory holidays, relief/ replacement hours for vacation and sick days, overtime and callback hours paid and banked and attendance at committee meetings and informal education. Paid hours includes all worked hours, with the addition of vacations, statutory holidays, and benefits.

It is difficult to accurately compare Ontario with other Canadian jurisdictions given differences in measurement. In terms of paid care hours per resident, Alberta reports providing 3.6 hours of nursing and personal support with an additional 0.4 hours from allied healthcare providers. footnote 31 [31] British Columbia provides 3.6 worked hours, with additional direct care from allied health care providers. footnote 32 [32]

Paid direct hours of care per resident per day in Ontario footnote 33 [33] Year Personal care hours Nursing hours Allied health and program support hours 2009 2.1 0.85 0.26 2010 2.11 0.87 0.29 2011 1.9 1.1 0.3 2012 2.16 0.95 0.31 2013 2.16 0.96 0.3 2014 2.19 0.95 0.36 2015 2.21 0.96 0.36 2016 2.22 0.97 0.37 2017 2.24 0.98 0.37 2018 2.3 1.03 0.4

9.6% the number of registered nursing staff in the long-term care sector in has increased by 9.6% since 2013. However, the proportion of registered nurses in the long-term care sector has decreased over the same time period, while the proportion of registered practical nurses and personal support workers has increased.

Eighty one percent of residents have some type of cognitive impairment, and often residents have advanced and ongoing medical conditions, and rely on multiple drug therapies to manage them. footnote 43 [43] The demand for such services is high. As Ontario's elderly population continues to grow, the need for long-term care services, and the needs of residents within long-term care, will continue to rise.

The current long-term care waitlist is over 38,000 individuals. In general, priority on the waitlist is provided to those with the highest care needs. footnote 44 [44] The average wait time is currently 152 days, and in that time, resident needs may continue to increase. As such, long-term care becomes the home of increasingly ill people, often in the end stage of their life, with higher acuity and care needs than other care settings.

ase Mix Index: (CMI) is a measure of average resource need to address resident needs in the province, and/or home. From 2004-2009 the provincial CMI score increased by 12.2%, and by another 7.6% from 2009 to 2018.

he method for assigning priority level: (MAPLe) is a score used by care coordinators to classify long-term care applicants as potential low, moderate, high, or very high-need residents, based on their medical status, cognition, behaviour, physical functioning before they are admitted to long-term care homes. The number of applicants with high or very high MAPLe scores was 82% in 2012, and increased to 85% in 2018, and 87% in 2019.

Concerns were expressed that funding has not kept pace with rising resident acuity. Annual investment in the acuity-adjusted NPC envelope increased at an average of 2.5% per year (from $82.43 per diem in 2009-2010 to $102.34 per diem in 2019-2020, an increase of approximately $4.53 accounting for inflation). footnote 48 [48] Similarly, funding provided in the PSS envelope (including physiotherapy) increased by an average of 4.4% per year (from $8.11 per diem in 2009-2010 to $12.06 per diem in 2019-2020. An increase of $2.44 in real terms). footnote 49 [49] In the same timeframe, total long-term care funding for staffing and all other priorities increased by 33.4%, from $3.26 billion in 2009 to 2010 to $4.35 billion in 2019 to 2020. footnote 50 [50] Accounting for inflation, this is an increase of $481 million, or 11%.

As the demand for long-term care has increased, healthcare staffing levels have not kept pace. The Canadian Institute for Health Information has documented a decline in the nursing workforce, as have Ontario nursing associations. footnote 51 [51] , footnote 52 [52] , footnote 53 [53] Shortages have also been noted in PSWs. For example, approximately 6,500 PSWs graduated from an Ontario PSW training program in 2018-2019 footnote 54 [54] , and each year, approximately 40% of PSW graduates leave their job within the year following graduation. In addition, it is estimated that approximately 25% of working PSWs who have two or more years of experience leave the profession each year.

…homes can be short five to 10 PSWs in every 24-hour period. Some homes [at the meeting said they] are short 20 to 50 PSWs. The situation is worse in Northern Ontario and rural areas, but the crisis exists even in the large cities of Southern Ontario. In one rural town near London, a long-term care home reported that there were only eight days of 365 in which they were fully staffed. footnote 55 [55]

As a result of these shortages, staff often do not have enough time to provide high-quality and holistic care to residents. For example: footnote 56 [56] Operators reported missed baths, missed personal care, and a lack of toileting, among other basic care functions. This was attributed to a lack of sufficient direct care per resident per day. It was reported that PSWs are often rushed and therefore cut corners to optimize the time they have available. As a result, residents may experience increased falls, levels of depression, infections, errors, complaints, anxiety, and conflict. A labour union reported that two-thirds of PSWs and nursing staff that were polled reported that they had to tell a resident they did not have time to take them to the washroom, and the resident would then have to wait.

The healthcare sector ranks second highest for injuries resulting in time lost in Ontario, and long-term care workers are among the most at risk for physical injury within the sector. footnote 57 [57] , footnote 58 [58] As of 2015, the Workplace Safety and Insurance Board, reported 3,822 injuries among the long-term care workforce which did not result in the worker needing time off, and 1,747 which did require time off. These injuries represent 27% of total injuries resulting in time lost in the health care sector. The most common reasons for injuries requiring leave were musculoskeletal disorders (38%), exposure to contaminants or chemicals (31%), slips, trips and falls (11%), and workplace violence (9%). footnote 59 [59] , footnote 60 [60]

Another issue for staff is the lack of full-time positions for those who want them. Staff often need to work multiple part-time jobs in order to achieve a living wage.

Some organizations report a disparity between the PSWs' educational experience and reality of the long-term care work environment. While educators tend to teach to the ideal environment, the pace and nature of work in long-term care can be more challenging than what students are prepared for in training.

On average, residents in long-term care homes are 84 years old.

The current demand for key positions, such as PSWs and RNs, outpaces the supply.

This comes at a time when the population of Ontario is aging. The growth in population over age 65 has outpaced that of labour-force aged Ontarians. This has resulted in a lack of balance in the care sector, felt particularly in long-term care. The OECD estimates that by 2040, Canada will require an 80% increase in all healthcare staff (across sectors) in order to maintain the current ratio of healthcare staff to individuals 65 and over.

As long-term care is already experiencing shortages that put resident care at risk, considerable improvements to workforce attraction and retention are needed to address this gap, in addition to increases in the overall pool of qualified candidates from the education sector.

Long-term care is sometimes perceived as a less desirable career choice compared to acute care.

There is also a perception that long-term care is low paying, physically challenging, and undervalued work as compared to other healthcare sectors such as the hospital sector, and that long-term care offers chronically casual work without benefits.

Long-term care is often spoken of as if it was a "dead end job" with little opportunity for advancement or reward. The proliferation of these perceptions can negatively impact the desirability of the sector and deter individuals from considering a career in long-term care.

In conclusion, the rate of growth in resident needs has outpaced staffing levels, education and training, as well as funding. Yet, long-term care employees are often passionate about their work and care deeply about the well-being of the residents.

The current staffing framework does not support a consistent, high quality of care for long-term care residents. Over time, working conditions for long-term care staff have become difficult; staff report being overworked, lacking support, and being asked to do 'more with less' every day. Many long-term care employees are frustrated that they cannot consistently provide the high-quality care that the residents deserve. As the long-term care system is set to expand significantly to respond to increasing demand, the current approach to staffing is not adequate.

The legislation and regulations are the framework for safeguarding resident rights and improving the quality of care. It has, however, been criticized by operators and associations for being overly prescriptive and onerous. In particular, educational requirements in this framework can be a barrier to exploring potential solutions for staffing issues.

Long-term care partners often cite the legislative and regulatory framework, inspections, and the funding model as interrelated provincial barriers which impact long-term care staffing.

Operators and associations also cite requirements that they feel are out of alignment with other areas on the continuum of care, particularly around the educational requirements needed to complete certain tasks or fill certain roles.

In general, the legislative and regulatory environment is criticized as being overly prescriptive limiting flexibility in how long-term care staff can respond to the diverse needs and desires of residents.

Operators have expressed that they find the funding model to be complex, and it has been the subject of criticism in consultations and submissions to government.

Some long-term care organizations state that the current methodology for documenting and inputting requests for additional needs-based funding is onerous, time consuming, and does not reflect real-time needs, as financial decisions can be based on data from two years prior. In these circumstances, additional funding for staffing to support higher acuity residents may be received after the resident is no longer at the home.

Resident health outcomes can be improved with high quality care, however, there is a perception that the funding model disincentivizes these efforts. The CMI prioritizes funding based on the need for resources. If health outcomes in a home improve, the CMI may show a lower need for resources in that home than elsewhere in the province. Consequently, the home's funding may fall the following year. This may inadvertently provide disincentives to homes from doing the best work they can. footnote 73 [73

Resident health outcomes can be improved with high quality care, however, there is a perception that the funding model disincentivizes these efforts. The CMI prioritizes funding based on the need for resources. If health outcomes in a home improve, the CMI may show a lower need for resources in that home than elsewhere in the province. Consequently, the home's funding may fall the following year. This may inadvertently provide disincentives to homes from doing the best work they can.

Long-term care staffing issues need to be considered within the context of the broader continuum of care and the mobility of the labour force across the health care system and beyond. Care should be taken to ensure that measures intended to improve staffing in the long-term care sector do not have unintended consequences on other sectors such as home and community care.

It would be inaccurate to say that all long-term care homes are experiencing a staffing crisis. But considering the sector as a whole, the word "crisis" is appropriate. Change is urgently needed, not only to address current issues, but also to prepare for the planned development of new long-term care beds. There is a need for immediate action to stabilize and augment staffing, but also to support longer-term reform.

Not all long-term care homes have a staffing crisis, but all are experiencing challenges. This situation existed long before the COVID-19 outbreak, although the pandemic further exposed these issues. Many reports have documented the difficulties in attracting and retaining staff, particularly for PSW and RN positions. Staffing challenges, including challenging working conditions, were highlighted by Justice Gillese in the Report of the Inquiry into the Safety and Security of Residents in the Long-Term Care Home System (the Gillese Inquiry).

It would be inaccurate to say that all long-term care homes are experiencing a staffing crisis. But considering the sector as a whole, the word "crisis" is appropriate. Change is urgently needed, not only to address current issues, but also to prepare for the planned development of new long-term care beds. There is a need for immediate action to stabilize and augment staffing, but also to support longer-term reform.

Priority areas for action The study itself is broad in scope, reflecting a wide range of inter-related and complex issues. It is impossible to address all of the issues we have heard about in one study under limited time. As such, we have identified five key priorities for immediate action. The number of staff working in long-term care needs to increase and more funding will be required to achieve that goal The culture of long-term care needs to change – at both the system and individual home level Workload and working conditions must get better, to retain staff and improve the conditions for care Excellence in long-term care requires effective leadership and access to specialized expertise Attract and prepare the right people for employment in long-term care, and provide opportunities for learning and growth

Workload and working conditions must get better, to retain staff and improve the conditions for care

Quality of care and quality of life for long-term care residents are significantly impacted by the long-term care labour force, which is currently spread far too thin. The acuity of residents has risen 20% between 2004 and 2018 based on CMI data, and the need for long-term care has also increased. Staffing has not kept pace with the medical needs of increasingly frail and elderly residents, neither in number of staff or in specialized expertise.

The focus on administrative tasks also takes time away from direct care.

Long-term care cannot become a better place to work, nor a better place to live, without increases to staffing levels. It is important to note that higher numbers of staff can only be achieved if there is an increased pool of interested and qualified potential employees, ready to pursue a career in long-term care. Moving forward with these priority recommendations should make it easier to attract and retain staff to work in long-term care.

Addressing staffing shortages in long-term care cannot happen without additional funding. The government can be confident that any increased investment will go directly to staffing by placing that funding in the dedicated envelopes which support staff costs (for example, the NPC and PSS envelopes). If homes do not spend funding provided through these envelopes on staff, the funding is recovered.

Addressing staffing shortages in long-term care cannot happen without additional funding. The government can be confident that any increased investment will go directly to staffing by placing that funding in the dedicated envelopes which support staff costs (for example, the NPC and PSS envelopes). If homes do not spend funding provided through these envelopes on staff, the funding is recovered.

We heard broad consensus from operators, professional associations, labour unions and sector representatives that the number of direct care hours per resident per day needs to increase to alleviate staffing pressures and support resident quality of life. We urge the ministry to move towards a minimum daily average of four hours of direct care per resident as quickly as possible. Achieving this objective will require funding support, in addition to a larger pool of trained staff. This number should be based on hours worked, rather than hours paid. The current measure of direct care hours in Ontario includes PSW, nursing, and allied health professionals. Given rising resident acuity, some think that this minimum daily average of four hours should be provided to residents by PSW and nursing staff, with allied health professionals captured as additional direct care hours.

We heard broad consensus from operators, professional associations, labour unions and sector representatives that the number of direct care hours per resident per day needs to increase to alleviate staffing pressures and support resident quality of life.

We urge the ministry to move towards a minimum daily average of four hours of direct care per resident as quickly as possible. Achieving this objective will require funding support, in addition to a larger pool of trained staff. This number should be based on hours worked, rather than hours paid.

The current measure of direct care hours in Ontario includes PSW, nursing, and allied health professionals. Given rising resident acuity, some think that this minimum daily average of four hours should be provided to residents by PSW and nursing staff, with allied health professionals captured as additional direct care hours.

We recognize there are differences of opinion about optimum staffing ratios and skill mix. Some long-term care partners recommend increasing the ratio of nursing staff to address higher acuity needs, in the place of some PSWs; while others want to see PSW levels maintained or increased to recognize the role of PSWs in supporting a range of daily physical and emotional needs.

We heard about the value of the varied expertise among long-term care staff, including registered staff, PSWs and other allied professionals such as physiotherapists, occupational therapists and social workers, among others. We recognize there are differences of opinion about optimum staffing ratios and skill mix. Some long-term care partners recommend increasing the ratio of nursing staff to address higher acuity needs, in the place of some PSWs; while others want to see PSW levels maintained or increased to recognize the role of PSWs in supporting a range of daily physical and emotional needs.

We believe that all care providers in long-term care have valuable expertise to support resident care needs, and the appropriate mix may depend on the specifics of the community and home – provided overall hours of direct care are increased.

Residents would benefit from more involvement by allied health and other professionals such as occupational therapists, physiotherapists, social workers, and recreation therapists on staff teams. Increased access to these professions is reported to increase strength and mobility, reduce trips and falls, improve sleep quality, and promote resident independence and quality of life. Improvements in medical outcomes, reductions in medication use and reductions in responsive behaviours may also be associated with increased involvement of these professional staff.

Taking this into consideration, we do not recommend regulating a specific staff mix or staff to resident ratios.

Instead, we recommend that the ministry establish staffing guidelines to allow some degree of flexibility to address the following factors:

Taking this into consideration, we do not recommend regulating a specific staff mix or staff to resident ratios. Instead, we recommend that the ministry establish staffing guidelines to allow some degree of flexibility to address the following factors: Resident population: In a home area with higher levels of cognitive impairment, residents may require more PSWs and recreation staff. Alternatively, in a home area with higher medical needs, more registered staff could be required. Regardless, all home areas need sufficient staff to address the medical complexity and vulnerability of their residents, as well as their social and emotional needs. Staff availability: In circumstances where PSWs are difficult to hire, inability to meet a targeted staffing ratio may be addressed for a period of time by involving different staff members with relevant training. Shift challenges: Ratios may appropriately vary at different times of day. While there is consensus that ratios can appropriately be lower on the night shift, there is concern these levels are often too low. Workload management: Task delegation and adjustment to workloads for specific staff may allow for some staff to increase the amount of direct care they can provide. For example, if some current administrative burdens on staff can be removed, they will be able to provide more hours of direct care. Team-based approaches to care may also impact the mix of staff. "Working short": Staff report that often they are "working short" when some staff scheduled for a shift are not able to report to work or complete their shift. There is no evidence on how prevalent this is and to what extent absenteeism needs to be taken into account in determining staffing levels.

Resident population: In a home area with higher levels of cognitive impairment, residents may require more PSWs and recreation staff.

Alternatively, in a home area with higher medical needs, more registered staff could be required.

Staff availability: In circumstances where PSWs are difficult to hire, inability to meet a targeted staffing ratio may be addressed for a period of time by involving different staff members with relevant training.

Given all these considerations, we recommend the following: A guideline of one PSW to eight residents be adopted for the day and evening shifts. Given the considerations above, this ratio would not be regulated. Over time, the government should work towards a guideline of one PSW to six residents. Overnight shifts can accommodate a higher ratio, but we are concerned that the current typical ratios for night coverage, sometimes as high as one PSW to 32 residents puts residents and staff at risk. The ministry should identify a more appropriate ratio for the overnight shift, and work towards it.

Given all these considerations, we recommend the following: A guideline of one PSW to eight residents be adopted for the day and evening shifts. Given the considerations above, this ratio would not be regulated. Over time, the government should work towards a guideline of one PSW to six residents. Overnight shifts can accommodate a higher ratio, but we are concerned that the current typical ratios for night coverage, sometimes as high as one PSW to 32 residents puts residents and staff at risk. The ministry should identify a more appropriate ratio for the overnight shift, and work towards it. The current requirement for at least one RN to be present and on duty at all times should be maintained. However, the requirement should be updated to consider home size as one RN is not sufficient to meet resident needs in larger homes. Sufficient levels of registered nursing staff are needed to provide greater clinical oversight and expertise to the care team, as well as to enhance direct care. Consideration should be given by homes to the mix of specialized expertise among registered staff, such as geriatric or wound care specialties. Additional access should be provided to allied health professionals as fully integrated members of the care team. Ensuring resident access to the expertise these professions bring is an important focus of geriatric medicine and an elder approach to care.

The current requirement for at least one RN to be present and on duty at all times should be maintained. However, the requirement should be updated to consider home size as one RN is not sufficient to meet resident needs in larger homes.

Sufficient levels of registered nursing staff are needed to provide greater clinical oversight and expertise to the care team, as well as to enhance direct care.

The consequence, as reported by long-term care partners, is that staff become overly focused on regulated tasks sometimes at the expense of positive resident outcomes.

In order to best meet the needs of residents and build a high-performing workforce, the culture of the long-term care sector needs to change. A continuous quality improvement approach that places residents at the centre of care should be adopted.

Regulatory modernization The goal of the legislation, regulation, and policies is to ensure all homes meet minimum standards. They create the standards, procedures and requirements for operations and provide the mechanisms for oversight and correction when necessary. A regulatory regime is important to ensure resident safety is maintained, while providing assurance to residents and their families that long-term care homes and the sector operate in the best interests of the people of Ontario. However, the current regime is not consistently achieving the desired result and has been widely criticized. It is a significant factor in the current culture of long-term care in Ontario.

We recommend the ministry review the regulatory framework to ensure it is consistent with, and supports, the goal of true resident-centered care. The regulatory environment can set minimum requirements while also encouraging continuous quality improvement in the sector.

We recommend the ministry review the regulatory framework to ensure it is consistent with, and supports, the goal of true resident-centered care. The regulatory environment can set minimum requirements while also encouraging continuous quality improvement in the sector. Not only can this contribute to culture change, it can also contribute to improved desirability of the sector as a career destination.

Effective oversight is crucial to ensure that minimum standards of care are met. However, we heard consistently that the approach in recent years has contributed to a sense of fear and a focus on compliance, sometimes to the detriment of resident outcomes. Adopting a quality improvement model, where compliance is understood as part of a journey to continuously improved care, could improve the culture in the sector. It is important to note that this type of approach does not disregard the importance of compliance nor the ability for the province to take corrective action where necessary. Instead, it positions compliance as one element in a broader model focused on moving homes towards excellence and placing residents' needs at the centre of care.

We recommend that the ministry adopt a quality improvement approach to sector oversight, and that inspection protocols be reviewed in that context. Inspectors should be able to identify issues and act as a resource, as well as work with operators to identify appropriate improvement strategies moving forward.

Measuring what matters is key in any quality improvement model and there are many examples in long-term care and the broader health care sector to be considered and built upon.

Measuring resident quality of life is essential to understanding how the long-term care sector is performing. Yet, no standardized approach is currently used. Homes are required to conduct patient satisfaction surveys annually. However, these are not standardized, and the data is not shared to help homes understand how their results compare, and where they can improve, relative to their peers.

There are some standardized metrics that can be leveraged within the long-term care sector. For example, there are some long-term care organizations that use the interRAI quality of life measurements and compare themselves internationally in collaboration with the Seniors Quality Leap Initiative.

[76] These evidence-based indicators can be used to provide accurate benchmarking for Ontario long-term care homes. Additionally, quality of life improvements have been included in Health Quality Ontario's Quality Improvement Plan (QIP) program for long-term care homes, and resident experiences has been recently added.

Quality of Clinical Care could also be a focus of performance measurement. Current evaluations are heavily based on clinical outcomes and could be expanded to include mental health and wellbeing metrics.

Homes that implement emotional models of care have shown improvements to the well-being and quality of life of residents, reduced the number of falls and use of anti-psychotic drugs, as well as increased staff engagement and reduced staff turnover, sickness and absenteeism.

The work they undertake is physically and emotionally taxing, which is exacerbated by the severe shortages of PSWs in many long-term care homes. PSWs report the need for support so they can deliver the holistic, quality care that residents deserve, and that they wish to provide.

Despite being critical to the success of the long-term care sector, PSWs are often not acknowledged as full members of the team. In order to better recognize their critical role, homes should fully integrate PSWs into the care team, drawing on their perspectives and knowledge of residents in care planning and case conferencing. Homes should also explore leadership opportunities for PSWs such as mentorship and preceptorship roles for new PSWs, education and auditing, peer-to-peer support, and "lead hand" positions which would provide guidance to PSW teams.

A number of our recommendations throughout this study are intended to recognize and support the critical role of PSWs. However, consideration should be given to additional ways to further professionalize the PSW role within the long-term care sector.

Some organizations, including labour unions, emphasize that compensation (salary and benefits) is an important factor to improve working conditions, particularly for PSWs. In some cases, full-time staff are taking on additional part-time work or casual work.

In Ontario, employment contracts within long-term care homes on average feature wages similar to or lower than acute care, and higher than those offered in home and community care. Lack of wage and benefit parity across the care continuum can contribute to labour challenges, and could be a possible deterrent, to working in long-term care. Any steps to address compensation need to consider the labour market across the health care sector as a whole. For example, increasing PSW wages in the long-term care sector only, would likely have a significant negative impact on recruitment and retention in the home and community care sector, leading to instability in the health care system as a whole.

Taking this into account, we recommend the ministry take an evidence-based, and systemic approach to compensation across health care settings and across occupations. Compensation parity should be strongly considered across settings and occupations to reduce compensation-related labour shortages.

Further, staff benefits can differ between full-time and part-time positions as well as across sectors. Full-time staff are typically offered full benefits, and part-time staff are typically provided either pro-rated benefits, or additional pay in-lieu. However, these practices may not be universal. Consideration should be given to standardizing benefit minimums to remove any real or perceived financial incentive to disproportionately hire part-time staff.

In addition, paid sick leave is not universal. As highlighted during the COVID-19 pandemic, staff who are ill need to be supported so they can remain away from the workplace until it is safe to return.

Benefits should be included in the consideration of compensation parity between sectors.

Many staff and long-term care partners call for more full-time positions to allow for more stable working conditions, and to reduce the number of individuals working multiple part-time jobs. Increasing the proportion of full-time, permanent positions would improve working conditions for staff and reduce the likelihood of spreading viruses, such as COVID-19, between homes.

Some homes have experimented with 12-hour shifts as one way to increase full-time positions. While some staff may be willing to work 12-hour shifts, workload of PSWs may be too physically intensive for this shift length. Anecdotally, where implemented, 12-hour shifts result in increased injuries and absenteeism.

We recommend that the sector work to share experiences and leading practices in maximizing opportunities for full-time hours.

It is important to acknowledge the physical, mental, and emotional risks of working in long-term care. Health care is the second highest sector to report injuries requiring leave, and long-term care is a close second to hospitals within the sector.

PSW injuries are common from repeatedly performing resident transfers without proper equipment, such as ceiling lifts. Homes should increase the usage of ergonomic physical infrastructure, and supportive technology – which also helps residents receive dignified and safe care.

Through roundtable discussions and stakeholder consultations, it was made clear that many find current charting requirements to be onerous, and not conducive to a quality improvement approach. Modifications to this process, including streamlining metric requirements, and leveraging electronic charting, could ease efficiency and resident-focus issues. This would free up valuable time for increased direct care to residents and support a quality improvement approach.

Further, charting should be used primarily for clinical or medical purposes, not as a condition for funding. We recommend the ministry remove CMI from the funding methodology. Given the overall high and increasing level of acuity of residents across the sector, the ministry should consider whether it is necessary to have an acuity factor as part of the funding methodology.

One of the responsibilities that falls to nursing staff is the management of medications, which includes the stocking, administration, and reconciliation of drugs. The time requirements to support medication management can impact a nurse's ability to complete other important tasks, such as clinical oversight and direct care. To better manage this workload, consideration could be given to how pharmacy personnel could be brought onsite to manage pharmaceutical stock, address issues of polypharmacy, complete investigations of medication incidents, and improve medication safety practices such as medication reconciliation (often completed by nurses). footnote 83 [83] , footnote 84 [84] , footnote 85 [85] The transition of these tasks from nursing staff to pharmacy staff would allow more time for direct resident care and clinical oversight. footnote 86 [86]

Early lessons from COVID-19 demonstrate a distinct need for improved infection prevention and control (IPAC) expertise in all long-term care homes. Homes routinely deal with influenza A and B outbreaks, and registered and PSW staff learn infection control as part of their training. However, rapid spread of COVID-19 in some homes suggests that many initial infection prevention and control efforts were insufficient. Hospital resources were able to be deployed in many sites to assist, but this is not an appropriate long-term solution, except in urgent situations. While larger homes might be able to hire a fulltime IPAC specialist, many homes may not be able to do so. The ministry should take immediate action to ensure all homes can directly access IPAC expertise, whether through centralized or regional teams of long-term care IPAC experts and/or increasing training to existing home staff.

The current labour pool for many long-term care staff positions does not meet demand, and this will be exacerbated as staffing levels are increased and as the development of new homes proceeds. Current shortages are particularly acute for PSWs and RNs. However, careful health human resource planning will be required to ensure that adequate pools of staff are available and high turnover and industry exit rates are addressed. This requires simultaneous planning and action regarding recruitment and retention since low retention rates are a key driver of the need for high recruitment rates. The recommendations in previous sections should collectively improve the perceptions of long-term care as a career destination of choice. However, attention needs to also be given to the curriculum, onboarding, and ongoing support and development for staff.

It is difficult for a generic program to sufficiently prepare students for all possible employment settings. However, there may be opportunities to provide students with greater opportunities to build their skills and knowledge. The following opportunities should be considered and expanded:

Integrating onsite education and job training may be particularly beneficial for PSW education, as full-time schooling for the duration of the program length (minimum of 600 hours) takes potential PSWs out of the paid workforce and may be a deterrent for some potential students. Options where a trainee could work as a personal care aide while pursuing their PSW certification have been suggested.

On-site education can be very beneficial for students but is not a viable model where existing staff do not have time to provide mentorship and guidance. Preceptorship roles could be more widely introduced as additional staffing roles outside of the regular staffing complement. This can also offer important career development or enrichment for experienced staff looking for new challenges.

Micro-credentialing refers to the creation of short-term certification programs that can be available to existing employees to enhance their skills and their ability to work in a particular context or with residents who have specific care needs. In the long-term care context, micro-credentials for staff could include a geriatric or long-term care specialty or a dementia specialty. The development of accessible, specialty micro-credentials could enhance the professionalism of the PSW workforce.

While RPN and PSW roles are critical and rewarding careers, areas of key focus should be upskilling from RPN to RN, given current RN supply challenges. Supporting the progress of PSWs into RPN roles through this type of program is also an option.

C: Advisory group membership Zubin Austin, Professor, Leslie Dan Faculty of Pharmacy, University of Toronto Melissa Donskov, Executive Director at the Saint-Louis Residence and Élisabeth Bruyère Residence long-term care homes Sharon Goodwin, Senior Vice President, Home & Community Care, Victorian Order of Nurses Akos Hoffer, CEO, The Perley and Rideau Veterans' Health Centre Anita Plunkett, RPN, PSW instructor, Ontario Association of Adult and Continuing Education School Board Administrators (CESBA) PSW co-chair Kevin Queen, CEO and District Administrator, Kenora District Homes Dr. Paula Rochon, Vice-President Research and Senior Scientist, Women's College Research Institute James Schlegel, President and CEO, Schlegel Health Care Arthur Sweetman, Ontario Research Chair in Health Human Resources, McMaster University Grace Welch, Chair of the Champlain Region Family Council Network Advocacy Committee

41% of the personal support worker workforce in the health care sector are visible minorities

According to the Ontario Hospital Association, the combined hospital sector net deficit for April to November 2020 was $521 million, inclusive of expenses, lost revenue, and balanced budget plans not implemented due to COVID-19. In the year ahead, costs for the hospital sector are expected to increase more than four per cent annually as a result of inflation, growth, new volumes and labour increases.

To remain “financially whole,” OHA says, Ontario hospitals require reimbursement for all COVID-19 expenses and lost revenue, funding to help manage the provincial backlog of surgeries and an increase to base funding of 4.3 per cent, or $860 million, to account for labour costs, growth, and additional volumes.

Meanwhile, in December, SAH reported the province did approve funding to cover COVID-related expenditures for a period of 2020. It was not be included in September fiscal results but recorded in those of October. The figure has not been released.

On the day the letter was sent, Dale said he received a call from Merrilee Fullerton, Minister of Long-Term Care who expressed gratitude before making a startling comment.